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Home My WebLink About0050 BLACKBERRY LANE - Health 50 Blackberry Lane; j i Hyannis �•��,. � � - �- A= 249-078 ----- ----- - - ----- --- - - o o a i ..I l� r� v �a e A l� a o a I t TOWN OF BARNSTABLE fiK�s11�.1-Wl LOC TION SEWAGE # f —�1'� s VILLAGE lull - ASSESSOR'S'MAP & LOT� V9-67 5? INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY --1000 ae02 LEACHING FACILITY: (type) a !Ix -L (size) Q_ NO.OF BEDROOMS BUILDER OR OWNER 1-4- d 4.1,4 �} , PERMITDATE: PJ COMPLIANCE DATE: t 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 r Commonwealth of Massachusetts a��- ova Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary AssessmentsM ,.. #50 Blackberry Lane �b;d Property Address Cabral ` Owner Owner's Name z; information is required for every Hyannis MA 02601 07/28/2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 3 on the computer, use only the tab 1. Inspector: key to move your cursor-do not A.Riker use the return Name of Inspector key. Riker Land Construction � Company Name PO Box 726 Company Address South Yarmouth MA 02664 City/Town State Zip Code 508-776-6460 S14590 Telephone 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 07.28.2018 Inspe or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 i 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. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �0 W v�_T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. Cityrrown 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: Observation of septic tank,distribution box and area above SAS did not indicated any failures upon observation of these componets. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): J t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. Cityrrown State Zip Code Date of Inspection .B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 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 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 must be attached to this form. 3. Other: 1 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 0 ® 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 '/2 day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd: For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area.— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question.in Section E the system is considered a significant threat, or answered."yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 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? ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550GPD t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System is a single 1000 gallon precast septic tank H-10 , H-10 distribution box inside a H-20 riser with H-20 cover and two 50' long pert pipe trenches 4'wide by 2'deep. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2017=274 GPD 2016=220GPD Detail: COMM water district Records Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 4 Grease trap present? ❑ Yes ❑ No - r Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: current Date Other(describe below): General Information Pumping Records: Source of information: homeowner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Annual pumping recommended due to 1000gallon tank serviceing 5 bedroom dwelling 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5-Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Recordeds indicate installation in 05/02/1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): i Depth below grade: 2feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): No obvious leakage observed . Septic Tank(locate on site plan): Depth below grade: 1'feett Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon precast concrete tank with risers " If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5x5x8'6" Sludge depth: 811 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" 4' Scum thickness Distance from top of scum to top of outlet tee or baffle Orr Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No obvious failures observed , risers installed 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons 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 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Equal to two speed levelers 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.): NO high water stains observed Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain.why: Leach trenches probed for location t5ins.d6c•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2@50'Lx4'Wx2'D ❑ 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.): Soils above SAS were dry and free from effluent I 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 15im.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I k.. - yy� 13- 14CP"OL 3 r I • t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 950 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 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'high ground water: >12 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: Test Hole on file ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how 9 you established the high round water elevation: Y 9 Test Holes on file Before filing this Inspection Report, please see Report Completeness'Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments #50 Blackberry Lane Property Address Cabral Owner Owner's Name information is required for every Hyannis MA 02601 07/28/2018 page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 s loot Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is H annis MA 02601 03/30/14 required for every y page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, _ I use only the tab 1. Inspector: key to move your cursor-do not Kevin Cochran use the return Name of Inspector key. Aardvark Environmental Inspections �y Company Name P O Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 13356 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 04101/14 I 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 �1,jo�7Z and copies sent to the buyer, if applicable, and the approving authority. **"his 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. L/� v i �j• I t5ins-WU Title 5 Official trispection Form:SLbsuftce isposal system-P e 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is Hyannis MA 02601 03/30/14 required for every page. Cityrrown 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: ® 1 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: I 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. Check the box for"yes","no"or"not determined"(Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 ` Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): I ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 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 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 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 Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ® Any portion of cesspool or privy is within 100 feet.of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 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. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Fonn:Subsuftce Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 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? ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 6 Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. City/Town State Zip Code Date of Inspection D. System Information i Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of Date occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use Date Other(describe below): F General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest , inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. Cityrrown State Zip Code Date of Inspection D. System.Information (cunt.) Approximate age of all components, date installed (if known)and source of information: 05/02/97.per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: �t Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2.0 P 9 feet Material of construction: ® concrete ❑ metal. ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 3" l5ins•3113 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" 2„ Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan)`. Depth,below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness _ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 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.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Trraywick Owner Owners Name information is required for every Hyannis MA 02601 03/30/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps'in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. Cityrrown state Zip Code Date of Inspection D. System Information. (cunt.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2@4'x50' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): This system has two 4'x50'stone trenches. There was no sign of ponding or failure in the stones. i 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 F Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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.j: t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14'of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately rear 45 35 71 26 72 36 39 84 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 r i ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 i page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 20.0 Estimated depth to high 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: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts "upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Blackberry Lane Property Address Samuel Traywick Owner Owner's Name information is required for every Hyannis MA 02601 03/30/14 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked. ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of.Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 t . Commonwealth of Massachusetts Title 5 Official Inspection Form 5� Not for Voluntary Assessments L-11 � Subsurface Sewage Disposal System Form U Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611512000. Inspection forms may not be altered in any way. Important:When Z A. Certification filling out forms 1. Property Information: on the computer, use only the tab 50 Blackberry Lane, Hyannis, MA 02601 key to move your Property Address cursor-do not Eric Barsness use the return Owner's Name key. 50 Blackberry Lane ICI Owner's Address Hyannis MA 02601 Cityrrown State Zip Code Date of Inspection: Date 6/08 2. Inspector: Mike Hudson - DEP Lic#4254 Q Name of Inspector Septic-wiz Environmental Services Company Name �.1 31 Midway Dr O �J Company Address Centerville MA 02632 k City/Town State ; Zip C $ 508-367-5669 `= Telephone Number N M a ri Q Certification Statement: c : I certify that I have personally inspected the sewage disposal system at this address and--that ttg information reported below is true, accurate and complete as of the time of the in pectior;dhe t—Apection was performed based on my training and experience in the proper function and qaintenaeee ofrdn site sewage disposal systems. I am a DEP approved system inspector pursuant t _Secti6W 15.E of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furt0er Eval i6n by the Local Approving Authority 05/16/08 Inspector's ' 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. 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 50 Blackberry Ln Property Address Hyannis MA 02601 Cityrrown State Zip Code Eric Barsness 05/16/08 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ' ® 1 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: 41A — 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: 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r Subsurface Sewage Disposal System Form I A. Certification (cunt.) 50 Blackberry Ln Property Address Hyannis MA 02601 City/Town State Zip Code Eric Barsness 05/16/08 Owner's Name Date of Inspection J it, _ B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: P N _ 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 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 50 Blackberry Ln Property Address Hyannis MA 02601 Cityrrown State Zip Code Eric Barsness 05/16/08 Owners Name Date of Inspection i C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments s Subsurface Sewage Disposal System Form A. Certification (cont.) 50 Blackberry Ln Property Address Hyannis MA 02601 City/Town State ZipCode Eric Barsness 05/16/08 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 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 Yz 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. ❑ ® 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No El ® 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. 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) 50 Blackberry Ln Property Address Hyannis MA 02601 CityfTown State Zip Code Eric Barsness 05/16/08 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a `` design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 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 B. Checklist 50 Blackberry Ln Property Address HYannis MA 02601 City/Town State Zip Code Eric Barsness 05/16/08 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 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? El ® Have large volmes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ❑ ® Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 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 Subsurface Sewage Disposal System Form C. System Information 50 Blackberry Ln Property Address Hyannis MA 02601 Cityrrown State Zip Code Eric Barsness 05/16/08 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 0 Number of current residents: ` 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 Z No Seasonal use? ❑ Yes ® No 2006-14 GPD Water meter readings, if available(last 2 years usage(gpd)): 2007-60 GPD Sump pump? ❑ Yes Z No unknown Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No :Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water,meter readings, if available: Last date of occupancy/use: Date Other(describe): 50 Blackberry Ln(2)-T5 Inspedion.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 50 Blackberry Ln Property Address Hyannis MA 02601 Cityrrown State Zip Code Eric Barsness 05/16/08 Owner's Name Date of Inspection General Information Pumping Records: BOH, Water Pollution Control, Pumping Contractor- Source of information: Last pumped apol 2006 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) El maintenance 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: 11 years per as built plan dated 5-2-97 on file at Barnstable BOH •i Were sewage odors detected when arriving at the site? ❑ Yes ® No 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) 50 Blackberry Ln - Property Address Hyannis MA 02601 City/Town State Zip Code Eric Barsness 05/16/08 Owners Name Date of Inspection Building Sewer(locate on site plan): 2'10" Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/Afeet Comments(on condition of joints, venting, evidence of leakage, etc.): pipe appears to be in good condition no evidence of leakage Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) N/A If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ® No certificate) 8'6"Lx4'10'Wx5'8"H, 1000 gallon Dimensions: Sludge depth: no sludge at time of inspection Distance from top of sludge to bottom of outlet tee or baffle n/a no scum at time of inspection Scum thickness - . Distance from top of scum to top of outlet tee or baffle n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a probe, measuring stick, tape, How were dimensions determined? flashlight, mirror 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments UV Subsurface Sewage Disposal System Form C. System Information (cont.) 50 Blackberry Ln Property Address Hyannis MA 02601 City/Town State Zip Code Eric Barsness 05/16/08 Owners Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet baffle condition good, pvc outlet tee is new, tank structurally sound w/no evidence of leakage. Recommend scheduled pumpings every 36 months. NIA _ 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) 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 50 Blackberry Ln Property Address Hyannis MA 02601 Cityrrown State Zip Code Eric Barsness 05/16/08 Owner's Name Date of Inspection 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.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert .10, at outlet 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.): D box level and flowing evenly, no solids present structurally sound and no evidence of leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 50 Blackberry Ln(2)-T5 Inspecbon.doc•11/2004 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 12 of 16 i Commonwealth of Massachusetts ivTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 50 Blackberry Ln Property Address Hyannis MA 02601 Cityrrown State Zip Code Eric Barsness 05/16/08 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): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: (2)4'wx2'hx ® leaching trenches number, length: 50'1 ❑ 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.): loamy sand no signs of hydraulic failure no ponding damp soil or abnormally lush vegetation , I 50 Blackberry Ln(2)-T5 Inspection.doo•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 50 Blackberry Ln Property Address Hyannis MA 02601 Cityrrown State Zip Code Eric Barsness 05/16/08 Owners Name Date of Inspection lCesspools (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.): IPrivy(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.): 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 50 Blackberry Ln Property Address Hyannis MA 02601 Cityrrown State Zip Code Eric Barsness 05/16/08 Owner's Name Date of Inspection 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. A 1-39' B 1-25'6' W 2-35' 2-71' 50 Blackberry Ln Hyannis, MA 02601 5 Bedroom Rear of House A B 2 D-Box 1 O 1000 Gallon H-10 Septic Tank O I ,I • (2) 4'wx2'hx50'l leaching trenches 50 Blackberry Ln(2)-T5 lnspection.doc•112004 Title 5 Offal Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' C. System Information (cunt.) 50 Blackberry Ln Property Address Hyannis MA 02601 City/Town State Zip Code Eric Barsness 05/16/08 Owner's Name Date of Inspection Site Exam: Slope Surface water ,J Check cellar N /lr Shallow wells �,I Estimated depth to ground water: \yy Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design Ian reviewed: 04/19/06 9 p Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health explain: Reviewed as built ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: Reviewed USGS ground water map and geological survey map You must describe how you established the high ground water elevation: ` Reviewed USGS topo map and groundwater map for site location reviewed permit and as built. `=6. 50 Blackberry Ln(2)-T5 Inspection.doc•11/2004 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 oFt�r� Town of Barnstable o Regulatory Services BARNSI'ABI E ; Thomas F. Geiler,Director 039. ,�•� Public Health Division CFO MA'I Thomas McKean,Director 200�Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, .Department of Environmental Protection. Although the Town of Barnstable. Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIODisclaimer Private Septic Inspections.DOC No. -/ 7 s a 7d ` ' Fee 'SHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migogar *pgtem Construction permit Application for a ermit to Construct( )Repair(upgrade( )Abandon( ) ❑Complete System O Individual Components �Assess �A�ress r Lot No. Yr � Owner's Name,Address and Tel.No. or p el, • ' Z.�.W e"YS P�nv�- �� ' �� -O?�s ler's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. " - Type of Building: Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow S 75-0 gallons per day. Calculated daily flow 630 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank I bQ0 2' Fsr Type of S.A.S. Description of Soil IQ t, Nature of Repairs or Alterations(Answer whenapplicable) ��T_KA 0CjL' C1C1!1i MG ) 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 a not to place the system in operation until a Certifi- cate of Compliance has bee B owT o Signed Date d",4`3 7 Application Approved by A Date G ,9 2 Application Disapproved for the following reasons Permit No. 7 " . ?U Date Issued la —� iF..-.�3 -'�l:+s1L'«c'�o�w,ri.,f`"lyr,....,.. f.:".r ..,.. .� .,,.,r.. .r?-=Y+.... .:i�. '.L...r 'two. 1 Ft• _ .. , �•G..1. .,•.i. ._ � ,�... r; No. r. ,�?p Fee M-- "`� (IE"COMMONWEALTH OF MASSACHUSETTS Entered in computer: c Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zlpplication for Miopogaf 6potem Cow5truction Permit Application for a rmit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components a+ Loc dd�ss Lot No. % Q��GL '�_ �r (y Owner's Name,Address and Tel.No. Lo Assessor s JPaccel, 1✓ �'T`C W�" Linstilfer's Name,Address,and Tgl.No. Designer's Name,Address anf el.No., w. Type of Building: Dwelling No. of Bedrooms _ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 5 750 gallons per day. Calculated daily flow 1630 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ( h60 e,VCrS.T xe- --f Type of S.A.S. .Tr�e�w�s ' Description of Soil v , f Nature of Repairs or Alterations(Answer when applicable)_ �'V sTAA O d CKr�7 Gj�g��.j =4 AML_ LLQ O FT-`S t a�trc c (:ll ,a'X D Go�,�"6 .c 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 a d not to place the system in operation until a Certifi- cate of Compliance has been_ ued.b. B,;&bf Health. SignedDate 6-e-)L``j 7 Application Approved by !1 ' _ Date Application Disapproved for the,.following reasons . r Permit No. 7 a '7 U Date Issued 6 .2 —9 2 - t THE COMMONWEALTH OF MASSACHUSETTS , ti BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS.IS TO CER V- 2. e On,.si age Disposal System Constructed( )Repaired ( )Upgraded Abandoned( ' )by -e at 1 n" � bevr.r �r..ve _ ruD has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 7-, 20 dated 9 — 9 2 . Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will funcn tio as �1 . Date . Inspector -- — - ------------------------ ------v 9;7 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mioponl *pgtem 5on!'Argftton Permit Permission is hereby granted to Construct( )Repair(Loofljpgrade( f Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this peQmit. Date:_ _ 6 -„2 — �� Approved by r NOTICE: This Form is to be used for the Repair.of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL.: WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANSI:' ". . I, l✓o��Y� , hereby certify that the application for disposal;works construction Qi�lR permit SU sig�ed by me dated concerning.the . . property located at f 0 meetsall of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : , DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. ,., �s i ,. (® ` r. e ' Al ION SEWAGE PERMIT NO. -e c 6 VILLAGE INS A LLER'S NAME & ADDRESS 8U11DER OR OWNER DATE PERMIT' ISSUED DAT E 40 ISSUED `l Ii J G iR ..ft. n TOWN OF BARNSTABLE LOCATION SEWAGE # - 7 VILLAGE AA -07� � INSTALLER'S NAME A PHONE NO. X a-- SEPTIC TANK CAPACITY 1 oyo 0_,& .ate :. LEACHING FACILITY: (type) V X �L (size) Q_' S D /A NO.OF BEDROOMS >BUILDER OR OWNER _LION' a4e� ' PERMITDATE: OMPLIANCE DATE: 9 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 t hfl V i I A - , No.. .. ...:1.1�. Fimx.......................................... THE COMMONWEALTH OF MASSACHUSETTS p BOARD F HEALTH OF.......................................................... ........................... 'W AV.p iratiun for Bispwi al Works Tonotrnrtiun thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Location-Address or Lot No. — ... �� ... .......................................... .........•-----....._......_.........•••••. ..••••-------•••••-•••........................ wner Address a ----------------•---••........... Installer ' Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building— No. of persons............................ Showers Other—Type g�'---------------------------• P ( )..— Cafeteria ( ) Otherfixtures -------------------------- -----------------•---------.-----•-----------•-------•----•---••.......------------------ ......---• W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter------.......... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....................'Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) /' aPercolation Test Results Performed by.......................................................................... Date---------------....... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....-.-----.-.------.--. rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ---• ----------------------- ..........................--.............................................................. 0 Description of Soil_,�G r—�.------�..................................-..................................................... x .....--•-••---------------------------••••---------.........---........--- ----..........-•-----•--------------------------------...-----------------------------------------...------•-•---••----. W x ---------•--------•--------•--••----•-•--......•---•--------------•-----•----......-------•-•-•--------•-•---•---=-------•----------•-• --- ----- ------ U Nature of Repairs or Alterations—Answer when applicable... d.---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'L IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued b he board of health. / 15/Z Sign ........ .................•-----. ...--------..._-----•--•---------• /// Date Application Approved By.......... -- . -•--• = °Z -y-7.7...... Date Application Disapproved for the following reasons: ---------------•-.-- ----•- -- -- --------------------------------------------•••--...------•.......------.....•••------.......------.....•.--••-•-•.....••-•-----••-----•--------•-•-•-•-----•-------•--------------•--------•------------ O Date PermitNo........................................................ Issued.... 3 .... _. 77.......... Date t tz I—, J No. t 'T l®�' FEs........ ... :...... z THE COMMONWEALTH OF MASSACHUSETTS , BOAR F HEALTH. -4 .> �,. Appliration for Disposal Works Tunstrnrtiun Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage`Disposal S stem ..........•. .....•.. 7,e�,4 e Zee— ....... Lo t, Address or Lot No. Oyler Address rW1 `_....... :..`� ... : ........... ........ Installer Address' Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building'............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa/ Other fixtures ------------•--•-••----••-•---•- - W Design Flow...:..:.:..:..............................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid:'capacity...-.........gallons Length................ Width................ Diameter................. Depth................ x Disposal Trench—No. r....:............. 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. I................minutes per incli: Depth of Test Pit.................... Depth to ground water......................... Test Pit No..2................minutes per inch ; Depth of Test Pit.................... Depth to ground water........................ a ` O �G�.......fi r Description of Soil: s•. - -- - --------------------------------- .....----•---....._...•--•------------•-- •-•----•--•--•-•--•--........4- ----------------••-•-•-----•--•-••-•-•---•----...-------••-----.....----•-•---•-----------...---------••----.......-------- W .._....-•-- . ...... .: U Nature°of Repairs or Alterations—Answer when applicabI...l_�d.... ) .._ .:. _..:. _. ................................................•-------------------------------------------------------•------------•----------.d/---------------- ---------- ---.................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Ti IT 5 of the,State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has €n,isstied b the board of health: }t Si ------- -•-• .............................••--- / /-77` • n Dat Application Approved-BY {<'-•----. ----= ............. : ::...... :..._. Date Application Disapproved for the following = s reasons:-----•---------------------•--------------------•-----------•-•--•---•--•--•-•--•-------• p ------..------ .......................•-•------•....-•••-••-•-.. ........: ..........-•------••----------- •. ---.........Date.............. Permit No. r u........................................ ... -1 Issued_..� . ..-----•--•-•--•-- ; Da� �_- THE COM.MONWEALTH-OF MASSACHUSETTS •4_ w r l BOARD�OF HEALTH .•�„.............................. t.r7.... oF........:° ......... .......:...:.:......... .................. Ttftifiratr of uanpliFanre T S TO R FY hat the Individual Sewage Disposal System constructed ( ) or Repaired b, ----........ - .............. Y ,. M :.. � � ��/� f . '�..i G� L44��, sta r . ' ,has been installed in accordance with the provisions of TI 5 The ate Sanitary C de as described-in the :: / B• application for Disposal Works Construction Permit No________________ _ fj.___.......... dated_..:'!'..:...: .....7:_y._....: .:_.._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE, SYSTEhI dill L F FICTION SATISFACTORY C �•„�,�,, ,a,�+ss,2,�,s�,x��,�•�^.s...y, �:,�, u , r-•Yr• p;v.�.:� �rY�� ,t `o DATE - �a -�- - Ins ector ..................... - rt- .� p r f t is y n w •�` 'tv y'�.t v '' Y.� 1t 3 '.4•fi"' +L r,�f .w, t�M� s.!39,y�lby .atP.lt-,,+uE sty, .1,z} .,y'".Kh �i•-...,"�.�.P ..�.:.:._.,,,.,na��..w..3: .-'..,�'.."`'a`•�"y 1j3..;f�1�`t k.:i'K L�: f'rW,Y,*`.'V�1�a{k�k °i,>'�4i KZ 'i'•?�. C!i�:..��ff�a�e{.. i ....... .... h.e�...�6..�..y�"'7•rV•.'«YSS'"l::�'......�� ,., '� .. A; • a• THE COMMONWEALTH OF MASSACHUSETTS , r- BOARD OF .HEALTH' ` '70 n i' Y OF...... tor ....«A No..•-•--.•----- .. -- FEE._.......... RAVUS ork T.ignutrnrtti�an per it ' ' Perm> slom,is`hereby granted ....................................._ ................... t Con truct, ( ) R , it an ividual Sewa� pos tSy' as shown on the application for Disposal Works Constr ction rs t tNo .. °A.:�` Dated_._ _.. _ .PP PT• .t� l,-"=. -••--------------------------- " ,, "'7, Board of xealt . DATE-- •-• -•--- -•..••... . ................................. .3 ' FORM 1255 HOBBS & WARREN. INC,'`PUBLISHERS