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Home My WebLink About0057 SWIFT AVENUE - Health 57 Swift Avenue Osterville P c A = 165 035 , JCENGINEERING, Inc. Civil & Environmental Engineering ~ 2854 Cranberry Highway , East Wareham, Massachusetts 02538 Ph. 508-273-0377-Fax 508-273-0367 April 15, 2008 Thomas A. McKean , Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 RE: Existing Soil Absorption System (SAS) Located at 57 Swift Ave, Osterville, MA Dear Mr. McKean: Having conducted a site inspection of the existing SAS located at 57 Swift Ave, Osterville, MA, our office has determined the following: The SAS consists of one (1) 6'diameter leaching pit surrounded by approximately 2' of crushed stone. The top of the cover was found to be approximately 2' below grade and the pipe invert to be approximately P below the top of the cover. The total depth of the pit was measured to be approximately 7', which results in 6' of depth between the bottom of the leaching pit and pipe invert. We've calculated the capacity of this leaching pit relative to the 1978 Title V code (310 CMR 15.03(4)(e)) and present the following: 1.) Bottom area capacity = ( n x r2 ) x. 1.0 = (itx52 ) x1.0 78.5 gpd 2.) Sidewall area capacity= ( 2n x r ) x height x 2.5 ( 27cx5 ) x6' x2.5 = 471.2 gpd 3.) Total capacity = 78.5 gpd + 471.2 gpd 549.7 gpd Per the town of Barnstable's Assessors information, this dwelling is assessed as three (3) bedrooms. However; the homeowner wishes to create an additional bedroom, which would result in a total of four (4) bedrooms. The property is not located within a DEP approved Zone 2 and the capacity of the existing SAS exceeds the required flow design of 440 gpd for a 4 bedroom house. Therefore, the homeowner requests that the board of health permit the additional bedroom due to the fact that the existing SAS has the capacity of 549.7 gpd, which is greater than 440 gpd. required for a 4 bedroom dwelling. Barnstable Board of Health April 15, 2008 Page 2 Should you have any questions or comments, please do not hesitate to contact our office. Thank you for your assistance on this matter. Sincerely, John L. Churc ill, Jr., P.E. President JLC/mcp Cc: File Paul Caprio Anthony J�=1VIaroon Commonwealth of Massachusetts Title 5 Official Inspection Fora copy. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is required for every Cisterville MA 02655 June 13, 2013 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 on the computer, ((�� use only the tab 1. Inspector: I C ,key to move your v► U cursor-do not Patrick T. Sullivan ` use the return Name of Inspector key. Ready Rooter Excavating �y Company Name P.O. Box 89 Company Address Forestdale MA 02644 City/Town State Zip,Code 508-888-6055 SI 12843' Telephone Number License Number d B. Certification 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 the1ocal Approving Authority June 13, 2013 Inspector'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 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. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal`System-Page 1 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is required for every Osterville MA 02655 June 13, 2013 l 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: 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/E] ND will pass. Check the box fo "no" or"not deter ined" (Y, N, ND)for the following statements. If"not determined," plelain. The septic tank iand over 2 years old"or the septic tank(whether metal or not) is structurally unsound, exhibitantial infil tion or exfiltration or tank failure is imminent. System will pass inspection if the tank is placed with a complying septic tank as approved by the Board of Health. A metal septic l ss inspection if it is structurally sound, not leaking and if a Certificate of Compliance indit the tank is less than 20 years old is available. ❑ Y ❑ ❑ ND (Explain below): 15ins•3/13 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 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is required for every Osterville MA 02655 June 13, 2013 - 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(withyremoved ealth): ❑ broken pipe(s) ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution boed ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 ti es a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval f 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 Re ired by the Board of Health: ❑ Conditions exist which re uire further evaluation by the Board of Health in order to determine if the system is failing to otect 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 t system is not functioning in a manner which will protect public health, safety and the en ironment: ❑ 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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Swift Ave Property Address AnthonyMaroon Owner Owner's Name information is required for every Osterville MA 02655 June 13, 2013 page. Citylrown 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 7ande 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 an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided tha no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool . ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�° 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is Osterville' MA 02655 June 13 2013 required for every , page. Cityrrown 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 10.0 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 ❑ ❑ th/1WPor is within 4 'fet of a surface drinking water supply ❑ ❑ this wit . 200 feet of a tributary to a surface drinking water supply ❑ El th is I Gated in a nitrogen sensitive area (Interim Wellhead Protection Ar or a mapped Zone II of a public water supply well If you have answered "yy question in Section E the system is considered a significant threat, or answered "yes" in Sebove the large system has failed. The owner or operator of any large system considered a sighreat under Section E or failed under Section D shall upgrade the system in accordance wMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 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 ,.' 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is t required for every Osterville MA 02655 June 13, 2013 page. CityfTown 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 549.7 GPD' t5ins-3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 of 17 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Swift Ave Property Address Anthony Maroon Owner Owners Name information is required for every Osterville MA 02655 June 13, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Size of leach pit capacity was calculated by JC Engineering, Inc in a letter to the Board of Health dated April 15, 2008. The letter was asking for the upgrade to four bedrooms as the leach pit was able to handle the additional flow. 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 ears usage d 2011- 165 GPD g ( y 9 (gp ))' 2012- 195 GPD* Detail: `Most water usage during summer months due to irrigation and pool. Sump pump? - ❑ Yes ® No Last date of occupancy: September 2012 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.20 ): Gallons per day(gpd) Basis of design flow (seats/person sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding to present? ❑ Yes ❑ No Non-sanitary waste disc arged to the Title 5 system? ❑ Yes ❑ No Water meter reading , if available: l5ins•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 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is required for every Osterville MA 02655 June 13 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No previous records found Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1400 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance 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•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 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is required for every Osterville MA 02655 June 13 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installed 11/14/1996. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan):- Depth below grade: 1 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: 10.6' X 5.5'X 5' 1500 gallons Sludge depth: 6„ t5ins•3/13 Title 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 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is required for every Osterville MA 02655 June 13, 2013 page. Cityrrown 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 28" Scum thickness 12"at inlet 6" at outlet Distance from top of scum to top of outlet tee or baffle Not at operating level Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape measure and dip tube. 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 and outlet PVC tees in place. Liquid level 8" below outlet invert. Property has been vacant for 9 months. No leak found during pumping and cleaning of tank after inspection. Tank is H-10 loaded and not designed to be driven over. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal fiberglass El polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum t/topoftlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Swift Ave Property Address J Anthony Maroon Owner Owners Name information is required for every Osterville MA 02655 June 13, 2013 page. Cityrrown 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 /iberglass El 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 Forth:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is Osterville MA 02655 June 13, 2013 required for every _ page. City/Town 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 0 1. 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.): One inlet, one outlet. No solids carryover. No sign of high water staining over outlet invert Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pum/amber, ndition 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: r t5ins•3113 Title 5 Official Inspection Forth: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 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is required for every Osterville MA 02655 June 13, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6'X 6'w/2' of stone. ❑ leaching chambers number: ❑ Teaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit dry at time of inspection. Located-and inspected with camera. No sign of past hydraulic failure. 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 constructio 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 57 Swift Ave lug - Property Address Anthony Maroon Owner Owner's Name information is required for every Osterville MA 02655 June 13, 2013 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 o/signs ydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 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 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is Osterville MA 02665 June 13, 2013 required for every Cityrrown page State Zap 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 � I i pl 3 as ` Ok C) thins•3113 ride 5 offidal hmpacbm Form Sowrface S"w Uispossi system•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is required for every Osterville MA 02655 June 13, 2013 page. Cityrrown 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: >4 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: 1996 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: www.terraserver.com ma.water.usgs.gov You must describe how you established the high ground water elevation: Test hole in 1996 shows adjusted ground water> 13' below grade. Base of Leach pit 9' below grade. Accessed local ground water contours and topo mapping. No high ground water in area of system. 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Swift Ave Property Address Anthony Maroon Owner Owner's Name information is required for every Cisterville MA 02655 June 13, 2013 page. CityfTown 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 I i i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -7F` - Commonwealth of Massachusetts _ Title 5 Official Inspection Form M1 ' Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information Important: When filling out 1. Property Information: forms the computer, r,use 57 Swift Ave only the tab key Property Address to move your John &Andrea Morin cursor-do not use the return Owner's Name key. 57 Swift Ave Owner's Address Osterville MA 02655 Cityrrown State Zip Code I I few /N I I Date of Inspection: 2/9/2007 — Date 2. Inspector: Andrew Putnam Name of Inspector A&M Septic Inspection Company Name P.O. Box 5013 Company Address Osterville MA :02655 City/Town State 'Zip Code:_. 508-280-5859 n l Telephone Number i {- B. Certification I certify that I have personally inspected the sewage disposal system at this address and that'the d 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 main'ntenance•of ow site sewage disposal systems. 1 am a DEP approved system inspector pursuant to S ction 15'340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b the Loc proving Authority 2/16/2007 Inspect 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 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. , I -• ' f ` Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 57 Swift Ave Property Address Osterville MA 02655 Cityrrown State" Zip Code John &Andrea Morin 2/9/2007 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: B) System Conditionally Passes: NIA ❑ 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: x Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 57 Swift Ave Property Address Osterville MA 02655 City/Town State Zip Code John &Andrea Morin 2/9/2007 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): N/A ❑ 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: C) Further Evaluation is Required by the Board of Health: NIA ❑ 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 Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 57 Swift Ave Property Address Osterville MA 02655 City/Town State Zip Code John &Andrea Morin 2/9/2007 ` Owner's Name Date of Inspection C) further Evaluation is Required by the Board of Health(cont.): N/A 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 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: A , Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Fora R Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 57 Swift Ave Property Address Osterville MA 02655 Citylrown State Zip Code John &Andrea Morin 2/9/2007 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool - ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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. ❑ NIA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - El N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ N/A 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.] ❑ N/A The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. Yes No .❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. Morin septic.doc a 03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Certification (cont.) 57 Swift Ave Property Address Osterville MA 02655 City/Town State Zip Code John &Andrea Morin 2/9/2007 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 15,000 gpd. N/A 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. Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17 f 44- Commonwealth of Massachusetts Title 5 official Inspection Form ' Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 57 Swift Ave Property Address Osterville MA 02655 Cityrrown State Zip Code John&Andrea Morin 2/9/2007 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 theaprevious 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. ® El approximation 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)] Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Fora Not for Voluntary Assessments a Subsurface Sewage Disposal System Form D. System Information 57 Swift Ave Property Address Osterville MA 02655 City/Town State Zip Code John &Andrea Morin 2/9/2007 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A 9 ( y 9 (gp ))� Sump pump? ❑ 'Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: NIA 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): Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 57 Swift Ave Property address Osterville MA 02655 Cityrrown State Zip Code John &Andrea Morin 2/9/2007 Owner's Name Date of Inspection General Information Pumping Records: Source of information: N/A 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: Component age 12 years, certificate on file Board of Health Were sewage odors detected when arriving,at the site? ❑ Yes ® No Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspect-!on Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M D. System Information (cont.) 57 Swift Ave Property Address Osterville MA 02655 City/Town State Zip Code John &Andrea Morin 2/9/2007 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® cast iron 17140 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): There were no signs of leakage at time of inspection. Septic Tank(locate on site plan): 1' 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 ® Yes ❑ No certificate) --------------------------------------------------------------------------------------------------------------------------- Dimensions: 10'6"x 5'10"x 57' Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle 28 ' Scum thickness 4„ Distance from top of scum to top of outlet tee or baffle 3° Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Ground probing, measure stick, and measure tape Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10-of.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 57 Swift Ave Property Address Osterville MA 02655 City/Town State Zip Code John&Andrea Morin 2/9/2007 Owner's 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.): The inlet and outlet tees are PVC and appeared in satisfactory condition. The liquid level was observed at the 4" PVC exit line invert pipe. There were no observed signs of backup, breakout, leakage or hydraulic failure within or above the tank at time of inspection. Grease Trap(locate on site plan): N/A 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): N/A Depth below grade: Material of construction: ❑ concrete El metal ❑ fiberglass" ❑ polyethylene ❑ other(explain): 'Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 57 Swift Ave Property Address Osterville MA 02655 Cityrrown State Zip Code John &Andrea Morin 2/9/2007 Owner's Name Date of Inspection Tight or Holding Tank(cont.) N/A 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 working level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is 2' below grade . Box is clean and solid. No sign of overloading or solid carryover. Pump Chamber(locate on site plan): N/A Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form . D. System Information (cont.) 57 Swift Ave Property Address Osterville MA 02655 City/Town State Zip Code John &Andrea Morin 2/9/2007 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: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There is one 1000 gallon precast leaching pit approximately 3' below grade. Leaching pit functionally sound at time of inspection. . t - Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 s Commonwealth of Massachusetts Title 5 official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information'(cont.) 57 Swift Ave Property Address Osterville MA 02655 City/Town State Zip Code John&Andrea IModn 2/9/2007 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids Payer 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): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): • r Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 57 Swift Ave Property Address Osterville MA 02655 CityrFown State Zip Code John &Andrea Morin 2/9/2007 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. per i 3` o '3'iNK house t ` garage Morin septic.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M D. System Information (cont.) 57 Swift Ave Property Address Osterville MA 02655 City/Town State Zip Code John &Andrea Morin 2/9/2007 Owner's Name Date of Inspection Site Exam: e - Slope Surface water >100' Check cellar Dry Shallow wells Estimated depth to ground water: 20' 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: Approximated from U.S. Dept of Interior Geological Survey and U.S.G.S. groundwater maps. 20'separation distance to adjusted ground water provided is greater than the 4.0'separation distance required. Morin septic.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 16 of 17• i k s, HIGH GROUND-WATER LEVEL COMPUTATION Date: Site Location: 5w 141 Permit: Owner: Ta�i i t Phone: Contractor: t j-?, Phone: Notes: "h STEP'l Measure depth to water table , to nearest 1/10 ft. (depth is in feet below land surface) Date: 7i2lis mm/dd/yy feet below Is STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well \l _70 B) Water-level range zone STEP 3 Using monthly "Current Water Resources Conditions" determine current depth to water level for index well. ] r mm/yy STEP 4 Using Table of Potential Water Level Rise for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment. STEP 5 Estimate depth to high water by,subtracting the water-level adjustment (STEP 4) from a Y01 measured depth to water level at site (STEP 1). NOTE* Tables 1-9 "Potential Water-Level Rise" are attached as worksheets to this file. monthly index well data: www.capecodcommission.org/wells.htmi D ATE ;12/23 PROPERTY ADOREss: 57 --O�te2vi�ee, l7azz_------- JAN 0 6 2004 02(L55 -__- __------ _ TOWN OFBARNSTABLE HEALTH DEPT. On the at)ove date, I inspected the septic system-at the above address. Tnis system consists of the loll,owing: 1. 1- 1500 ga.e2on 3ept.ic .tank. MAP 2. 1-Diht2.igut.ion -ox. p3�j 3. 1- 1000 ga.e.eon paec.azt .eeach.ing pit. PARCEL Baseo on my inspection, I certify the following conditions: LOT 3 - -- 4. 7hiz .is a t.it.ee �,Zve .6e/21.ic zystem. (78 Code)_ 5. The .aepl is 3yztem .is .iiz /a/o/z.ea. wo2k.ing- .oade✓t at .the pae.sent t.itne. 6. Ua,3te wate2 .iz 36' ge.eow the .invea-t pipe o� .the .eeaeh.ing flit. SIGNATUR Fame _ JP_ _Macomber_ir : _--- �orTipanY : 91tl2t .P_,_ 0.09go0@r d_ Son, Inc , 00fe5S : �a _fit- ------ --- -- • _ _ _CefliPCxt.l_LR,_ Je . _2�632-0066 �^one _508 775• ) ) )8 t T„iS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY , JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachllelds Pumped & Installed Town Sewer Connections P 0 Box 66 Centervilie, MA 0263?-0066 775,3338 775-6412 I ' COMMONWEALTH OF MASSACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' DEPARTMENT OF ENVIRONMENTAL PROTECTION At t V. TITLE 5 OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.FORM PART A CERTIFICATION. Property Address: ..5 7 Swi7-0t 4ve 0,6Le zviLee,.Na.6.6. Owner's Name: /2aumond & Donna %.0_ou,& e Owner's Address: Sam Date of Inspection: 17 L/23 Nameof Inspector: (please print) lo.6el2h 1). l7acom&e2 aa. Company Name: 2, 1,.Naco:mle2 & Son .Inc.: Mailing Address: a Cen t e2vc Z Ze, c-.6.6. 02632 Telephone Number: 5 0 8—7 7 5-3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.:The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant tb Section.15r340 of Title 5(310 CMR 1500). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: I The system inspector shall 4bmit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has.a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving. authority. Notes and Comments ****.This report only describes conditions at the_time:of-inspection and under the conditions of use.at that time..This inspection:does not address how the system will perform:in:the:future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) Property Address: 5 7 Sw.i7P_.t Ave 0,6te2vc Owner: /Zaumorzd & t onna l'eou e Date of Inspection: 1212103 Inspection Summary: Check A,B,C,D or E/ALWAYS-complete all of Section D A . System.;Passes;' ti I have not found an information which indicates that any of the failure criteria described in 310 CMR 15.303 or in . 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tho .tv f` .0 'wU3tem zz -ih /22o12e/L wog .cng 3771,rz the /22ezent time. B. System.Conditionally Passes: 4.40 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken-or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval.of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I wPage 3 of 1 I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION(continued) Property Address: 57 Swil.t Ave 0,3te_1Lv,i_R,e,e, Nazz. OWner:RaUmond R Donna 1.90 ZZ ,e Date of Inspection: 1212103 C. Further Evaluation is Required by the Board of Health: ,C�A9 Conditions exist which require further evaluation by the Board of Health:.in order,to.determine if he 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 environrirent: .L�11 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: �Q 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 aseptic tank and SAS and the SAS isvithin a Zone I 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 I Op feet.but 0 feet or rhore front 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: s 3 i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL; SYSTEM INSPECTION FORM PART A CERTIFICATION(continued-) Property Address: 5 7 S w.i�R_ 4 v e 0,6.tezv e, Ala,3;s. Owner: Raymond 9 Donna Piou,,,0e Date of Inspection: 1212103 D. System Failure.Criteria applicable to all systems:. You.must indicate"yes".or"no to.each of the following ifor all inspections: Yes No Backup of sewage into facility.or system component due to overloaded.or.clogged SAS or cesspool 7/Discharge:or,ponding.of effluent.to the surface ofahe.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 Ll quid depth insesspeol is less than 6' below invert or available,volume is less than'/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 . y portion of the SAS,cesspool or privy is below high ground water elevation. �VAny 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 l of a:.publlc well.. _ y portion of a cesspool or privy is within:50 feet of a private water supply well. y portion of a cesspool or-privy is less,than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This systempasses-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 foam.] . (Yes/No)The system fails.I have determined that one or::more_of the.-above failure>criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner.should.contact the Board of Health to determine what will be necessary to correct the failure.- E. Large Systems: To be considered a large system the system must serve a facility with.a design flow of 101000.gpd to 15;000. gpd, You must indicate either"yes"or"no"to,each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no/ / the system is within 400 feet of a surface drinking water supply %_/the system is within 200 feet of a tributary.to a surface drinking water supply 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. 4 >Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SU$SURFACE:SEWAGE DISPOSAUSYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 57 Sw.i"'.t 4ve Ozte2v.i—p e. Ma.6,3. Owner: /2aumorzd 9 Donna ),eou��e Date of Inspection: 1212103 Check if the following have been done.You trust indicate"yes or"no"`as to each..of fhe.following: . Yes Now . F/ 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 avail able'note as N/A) . _ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signsof break out yy _ Were all system components,-Acluding 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: Yes no Existing information.For example,a plan at the Board of Health. e-"""_ 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)] 5 Page 6 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,T SYSTEM INFORMATION Property Address: 57 SW,.4 Aun #anv.il�.0_P� lylri.t.S_ Owoer; RrjUmnnr/ . R 7nnnn 10 Pni'r o Date of Inspectlon: �2,( LO 1 FLOW CONDITIONS ,... RESIDENTIAL , Number of bedrooms (design): Number of bedrooms(actual): DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x M of bedrooms):0,47 Number of current residents; _ Does residence h>!ve a garbagc gander (yes or no): Is laundry on a separate sewage system (yes or no):,&, (if yes separate lnspectlon.required) Laundry system inspected es or no): Seasonal use: (yes or no):A Water meter readings, if available (last 2 years usage(gpd)):2001-71, 000 ga teonz=194. 52 gCP D Sump pump(ycs or no):A10 2002— 08, 000 ga-teon.6-295. 89 GPD, Last date of occupancy: Awd k COMMERCUUINDUSTRIAL Type of establishment: Design (low(based on 310 CMR 15.203): d Buis of design now(st&LVpersons/sgft,etc.): ? Grcase trap present(yes or no): /{ Industrial waste holding tank present (yes or no): AJ� Non•sanitnry waste discharged to the Title 5 system(yes or no): .� ) Water meter readings, if available; W Lass date of occupancy/use: Al OTHER (describe): �R GENERAL INFOR,MAT19#, Pumping Records Sourcc of information: None avaiiagie Wu system pumped as pan of the inspection(yes or no): If yes, volume pumped: ,gallons •• How was qutntiry pumped determined? Reason (or pumping; TYV OF SYSTEM _ZScptic tank distribution box, soil absorption system /L& Singic cesspool '2 Ovcrilow cesspool Privy Shand system(yes or no)(if yes, attach previous Inspection records, if any) 4C Innovative/AItemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) A2QTight tank h Atucb a copy of the DEP approval i�G cr(describe): �IQ Approximate ace of all compo c s, daft Installed(if . own) nd source of information; Were sewage odors detected when arriving at the site (yes or no).Ab . 6 f Pagc 7 or i i OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) P:ropeny Addre3s; 57 Swift' Ave U77icv.c�e. IVa.6 es Owner: Raumoncl &. [donna Teou ,Pe Date of 6rt;:pcetion: �Z/�/0� BUILDING SEWER(locate on site plan) r Dcpth below grade: !. Materials of consn-clion: cut iron 4 40 PVC other(txplatn) 144 Dis.tancc from private water supply well o suction line XI't Comments(on condition of joints,venting,tvidence of leakage,cit.). r�2 7o in_t.s nngv t�ahj No evidence o4 .Q'eakage The zyz.tem L3 vented .thIzough .the Zook ventz. SEPTIC TANK: Zoocatc on site plan) DVih bellow grade: ,v Material of construction.: v° concrete � metal fiberglass polyethylene. I r Urk is metal llst agc:M- !s age cgnfumcd by a CcrtlfScate of Compliar<co(yes or no):-! (attach a.copy of ccrtif►catc) r� r rr Dim.cnsion.s: 1D. r'� /JrrA rl Slud.gc depth.: Dis.tancc kom top of sludge to bonom of oullet tee or baffle:� Scum thiekncss;, _ Distance from top of scum to top of outlet tee or baffle:_ �� Distance born bottom of scum to bottom of outlet to or baffk�� How.were dimensions determined: I Co:mmcnts.(on pumping re.eortuncndations, tn.ict and outlet tee or baffle Bondi ion, structural integrity, liquid levels .as rclated.to out:lt.t invert, evidence of:lcakage,etc.): t P.um . .the ze .tic .tank even 2-3, yea.,zz.�Inie.t & ou.tie.t .teen a/ze tank 1. .6 2uc u2a" owuc -no e v t UT=e o� eeakage. L:iqu.id eve e at the ou.tie.t .inveic GREASE TRAEt (locate on site plank Depth Wow grads: Material of construetion.l Leoncrcte�lJRmctal. fib (cxPlaLn): crglus�poiyethylene other lV�9 � Dimenslons. Scum thickness: A j Distance from top of scum to top of outlet fcc yr baffle:.,,_ ol Distance from bottom of scum to bottom.of outlet tee or baffle; _ Date of Last pumping: Comments(on pumping recommendations,.inlet artd outlet tee or baffle condition,structural integrity, liquid levels as related to outict invert, tvidenceorleakage,etc,): (i2eaze t2aR ins no Rae�en Page 8 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SU SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 S.w.ile.t ,4ve Owner:._12,2Umond & Donna Date of Inspection: 12,12103 TIGHT or HOLDING TANK �(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: T Material of construcii :,concrete .G metal d14 fiberglass Log polyethylene,4z, other explain): Dimensions: Capacity: gallons Design Flow: 4/; gallons/day Alarm present(yes or no): Alarm level: ,(4 Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float'switches, etc.): 71,41 na h o d.ir p tank .ib not p/tezen DISTRIBUTION BOX: -,Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: /Oe) 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.): LiAiailution Sox hays one is e2a o ev.7 ence o o c No evidence o, eeakage into o2 out 07 the 9ox, PUMP CHAMBERV �'-(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.): 2iim�n r_hnmp 2 .ib no.t 122eben 8 Y Page 9 of 11 =• OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued): Property Address: 5 7 Sw.i It Ave Owner: Raumond & . Dorzaa l iou��e Date of Inspection: 121 2/D 3 SOIL ABSORPTION SYSTEM(SAS): ic✓ •(locate on site plan,excavation not required) 1000 as on a2eca,6;t Leaching pit. If SAS not located explain why: Sag Page In Type _leaching pits,number: l A',O leaching chambers,number: 6 Aj�leaching galleries,number:_CL leaching trenches,number, length: A)o leaching fields,number,dimensions:6 A)tl overflow cesspool,number:6 �. innovative/alternative system Type/name of technology:� �Pe /,0 eak Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �. Loamu sand .to medium 4inv irinr/ Nn 1 A' oP hydo asezr, Fr464op e � /2ortcl.ing Soiii iap day Voy_pfril inn_Lb raa4QQC CESSPOOLS (cesspool mutt-be pumped as part of inspection)(locate on site plan) Number and configuration: 0 Depth—top of liquid to inlet invert: AAA Depth of solids layer: Depth of scum layer: Dimensions of cesspool: B Materials of construction: Indication of groundwater inflow(yes or no): /Z Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): l 9AA QQPA nap nol 4,2 4a u i PRIYY,d &(locate on site plan) Materials of construction: 41 Dimensions: } Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ;9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS / SUg6URFACE°SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION(continued) Property.Address: 5 7 S w i v iS �2U-G.e-e8 �CGbb. owner:/laWa nr/ L-Doj u Date of Inspection: n SKETCH OF SEWAGE•DISPOSAL SYSTEM eferenQelandmarks or Provide a sketch of the sewage disposal i 00 feet Locate where public lwate u pleast two y ente stthe building. benchmarks.Locate all.wells within p 10 f Page I I of I I w �„ OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: 57 Sw"i,,E.t AL)e Owner: / nUmon.rl X. Don rue l Qoulo e Date of inspection: '21 2l n 3 SITE EXAM Slope Surface water Check cellar Shallow wells P ' Estimated depth to g7ound water feet Please indicate (check)all methods used to determine the NO ground water elevation: NO Obtained from system design plans on record • If checked,date of design plan reviewed: NA //CS Observed site (abutting property/observation hole within ISO feet.of SAS) NO Checked with local Board of Health-explain: NA � —Checked with local excavators, installers. (attach documentation) q 6 Accessed USGSdatabase-explain: h"tt/a://town. a2n�ta��e. You must describe how you established the high ground water elevation: 1,3ed: gah2e"tu 9 Riteea Nodee. 12/16/94 G2ound wa.te2 egevat.iorzz ¢dove zea �eveQ. Ized: USGS • 1992 Lied. IISGS Zaahn :nn0 gizUetin 92_0n0-1 10,Prj <o #2 nnua-e 2arzgee o� g1toun nn»rjlzy 9992 Leaching r Pit 40 :ect *TA, Groundwatcr. Feet Below Bottom of Pit High Groundwater Adjustment 1.8:ft per Fh.mpter Method T?tercfore, the vertical.separation distance between the boaom Of the leaching pit and the adjusted f feet. groundwater table is ��d' II t:,.rr.-.T ^rt,rr--n- •-1-err.nr.--rrs-�r•�e*r..r..r.:•.r.+•.rirr:.r-enr•-i rrrra-a:rrcc:rer.ms .. .. .. .Trrrrr .r—r.-..-._-_.. h 'TOWN OF Barnstable IlUARD OF HEALTH SUNSURFACR 9FWA(;E I)ISN-9AL SYSTF,M INSPECTION FORM - PART D .- CERTIFICATION I ...�..l.T......:,--,1!'^.�.T.T..�ffl'R:TT,TM1T•l'.TIiSTTTT'.'lrtlSirt�SiT"IPr�TR'•'�Tli'rNRRri'R'TILT4 TI111•11'IITT'fSiT �I'P•T'T•�. ^ TTTRT•.•.. �. —TYPO OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 57 Sw.i�t Rve U�ste2viE?E?e, lrla�s�. ASSESSORS MAP , BLOCK AND PARCEL OWNER' s NAME Raumon.d & Donna P-eou,&;ee _ PAR1' D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber V'ton Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street To" or City S t a t 9 11P COMPANY TELEPHONE ( 508 ) 775-3338 FAX ( 508 ) 790-1.578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of .. inspection- The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : ' � System PASSED The inspection which I have conducted has not found any information which indicates that th.e system fails to adequately protect public health or, Lhe 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�ailcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection. form , VInspectorSignature l�•ate ��--T . ne copy of thisi ' c.ification -must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF HEAL'1'It, * If the inspection FAILED , the owner or "o a rator ehall u.pgrade ' the eyetem wil;hin one year or the date of the inspection , unless allowed or required otherwise as provided in 3.10 CHR 16 , 305 , partd , doc 2—, 7.5w` .. val OF MMFES t�ooR 6> i No 33253 �---- ---T TOWN OF BARNSTABLE LOCATION `� ��°, V SEWAGE VILLAGE ASSESSOR'S MAP&PARCEL tMSTAttititS NAME&PHONE '}' �" 45- S9s-g ��Ss SEPTIC TANK CAPACITY ( �9� ��._ LEACHING FACILITY.(type) L-,ems l p;`ti (size) 6 NO.OF BEDROOMS OWNER ��1�.�� `IY� r e?✓�, PERMIT DATE: COMPLIANCE DATE: 4 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 7 �'� 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) �j Feet FURNISHED BY ,AcS�.� c7��J' X-mow e�cr� w o � �3 �l I Act i TOWN OF BARNSTABLE L(A,'ATION SEWAGE # VU.LAGE � i�=" f'_>.' �� ASSESSOR'S MAP&LOT .5 C-''.3;7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /0-5 L LEACHING FACILITY: (type) CX) c (size) r�, _- 1I0.OF BEDROOMS BUILDER OR OWNER !� !` H /?P PERMTfDATE: v"',�" �S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist • on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by R♦ �e �� i t S1, �• 4 � V/J.�./((// / \ / � /� � ` W ' J �� V G3 '� C . .................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Uinpoml Workii Tonitrnrtion ramit Application is hereby made for a Permit to Construct ( ) -or Repair ( an Individual Sewage Disposal System at: �,p 7 � rZ. a5 S �� 1� oc- on- ddress or Lot No. Owner Address W - Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms.3-----------------------_._--_---.-._ P" ............................)Showers Cafeteria ( )pa, Other—Type of Building ____________________________ No. of personsnsion Attic Cafeteria e Grinder ( ) 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. .................... 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........................................ 1.4 Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 04 ------------------------------•---------------------------------------------------------------............................................................... 0 Description of Soil........................................................................................................................................................................ w -------------------•------------•-------------........_....... --------------------- UNature of Repairs or Alterations—Answer when applicable.. L -•--------------•-•••--•--•-•--•-----------------•------•--•------•--•-••----•----•---------•-'.._...-----------• ------------------------------------------------------------------------'-----•------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental-Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance h s been ssued by the b rd of heap . Signed ...... .. ... .... . .� �. ...�� Application.Approved BY ...�-\�..`�. .--------------------------------------------------------------------.... Date Application Disapproved for the following rearonr- ---------------- ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- ---------------------------------- ---------------------------------------------------------------------------------------- ........................................ C1.5 p Date Permit No. -----:L.. -- ------------------ ' Issued ------------ .............. Date Fr*: .................... r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Di-riptual Wor1w C omitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ' an Individual Sewage Disposal System at - � -- CS......... �' �' If..`--- ----. .fi ....... ------.•-•-- .......... -••--------------•-------"------------- - ` Location- Nddress r. or Lot No. f ... �... ........• �� o q ----------------•----- -•----•--- ---••-•-•-----.........-------•----•-•---..... Address •^..•_• ............................. _ -.__.._-----------------•--_•------------------------------------------__- Installer Address UType of Building Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms.__________________________________.__Expansion Attic ( . Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------•---•------•----•--•------- •----- ............................................................... W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---.------------ Width_______________ Diameter-_. ------ Depth_;_------ x Disposal Trench—No. .................... Width.......------------- Total Length___...____--__.-._- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( ) -Dosing tank ( ) 0.4 Percolation Test Results Performed by............... ..................... .............................. Date.....................-------------•--- ..a Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f% Test Pit No. 2................minutes per inch Depth of Test Pit-------------....... Depth to ground water........................ 0 ----------------------------------------------------------..............................................................,.................................. D Description of Soil--------------•... ------. - V ............................................. ----------•--------------------••-•-•------------------------••---------. UW •••••••----•------------------ ---------------•----------------------------------------•---------- .............. --------- Nature of Repairs or Alterations—Answer when applicable_-' -- �--_ _�j _/r:._... �C" 6� .............. .--- --•-••--------•-•-•------•-----------------------•---•---•-•-•-----------------•--•-•-•••-....----••--------.--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System'in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'sued by the board of health Signed _. `.... . l!?. v it.: , �� -� ; A lication Approved B ---- 1 .... -----_.-..1..-�/.. PP PP Y ......_... V 4t^' "'� - - Date �1 ! Application Disapproved for the following rearons: --------------------------------- ----------..............------------------------------------- ------------------------------------------------------------------------------------------- ------------------------------------------------ ------------------------------------------------- ........................................ pp q Permit No. ......./_ f� `3 --------------------- ' Issued ..............�.... Date` Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (�e><#iftctt#e of IJ�IIm�littncE THISAA-INTO CERTIFY PThat the Individual Sewage Disposal System constructed ( ) or Repaired ( C/) by -- :�/.-: ...-- ^,11r�/: -!'-_---------------- at ........ . ,�� l�jt f�r'.. ---.....� .. . has been installed in accordance wit the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No- .------- �.:._-... .�5..V-...._. dated _..3_---..�__1. ...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIS CT RY. DATE_..... ./. �7 - - -..... Inspect .�G4.. �.._----r�91 I - ----------- ------_----•------._-------•-•-•-------- �--•-------_,_-j__.-_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.......5.:.. .�i L/ TOWN OF BARNSTABLE FEE_ ,......:......... Permission is hereby granted �t_. - --------------------------------------------------------------- to Construct ( ) or Repair,(--l")an In ividual Sewtw� age Disposal System J at No........g�°. ` .... -..e ... -�t_g- �� )c ' ) t /f l -.....-•••......--- _s---•------ r •--------100, r ,,.._y, C ,fC i Streefqq as shown on the application for Disposal Works Construction Permit No.,V------ __ Dated........3......>... r� ey i � Board of Health DATE............... f / --------------•------------••-... 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EDWARD ��N �t .��-= 141 ROUTE fiA o A. �`_, SALT POND BUILDING STONE n P.O.BOX 1729 q No. 28980 � ! SANDWICH,MA02563 LOT 2 a PARCEL ID: 165/034 1825 • ass O/STE J U" EDWA.RD A.5TONE N/F 3 i ELIZABETH A. & JOHN H. - ! � L LA o I7,p� CERT.TITLE V INSP.&SOIL EVAL. RPLS*28980 BOMMHARDT BUS:(508)98&3619 FAX:(508)8W2496 RES:(508)398-61313 - SHEET 1 OF 1 J 1126 t