HomeMy WebLinkAbout0098 SYLVAN LANE - Health 98 Sylvan / ,� - A-`
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Town of Barnstable P#
MIME rb
Department of Regulatory Services
BABr78TABLE. : .'Public HeaIth Division Date
y MASS.
:e39. �e� 200 Maiii Street,Hyannis MA 02601
�AlED MAC A AVZTirne
Date Scheduled _L_L� Fee Pd.
Soil Suitability.Assessment for Sewage Disposal
PerformedBy:. r;�Pt lt�iISM Witnessed By: yvY>l w, .
LOCATION & GENERAL INFORMATION
Location Address Owner's Name Sy Iv<.n ►'?,T,
98 Sy IVOA kA.Ac 00 Frr,/- l LV. P.b . rievyc v96
Address �SiCrvl it rVIA 0".(05,S
1
Assessor's'Map/Parcel: )�{(�/•11$ Engineer's Name S}aVhcn A W i I scr,a R C'
13,2vTr - W
NEW CONSTRUCTION REPAIR Telephone# p - /-7 Q , 4 l
Land Use IVZ4. ,rhG/ - Slopes(%) Surface Stones /7040
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line R Other. ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlIands in proximity to holes)
saw
tltl A
J�
Parent material(geologic) G&r_te I (>uh�e.9 4 Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: 'O
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment tt
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ C
PERCOLATION TEST Date-7-'— Time '/1,3 d
Observation
Hole# 3 Time at 9"
Depth of Pero 601, 70 11 Time at 6" p
Start Pre-soak Time n `/V // S®. Time(T.741) _
j�
End Pre-soak l :Z$ 'y-S U ' �t. ,to Soak F ,
�_ 4 U hor
Rate Min./Inch 4 ym, Z a',1 AA
Site SuitabilityAssessment: Site Passed V 0o"_ Site Failed: Additional Testing Needed(Y/N)
Originial: Public Health Division Observation Hole Data To Be Completed on Back----------- 0
(0
***If percolation test is to be conducted within 100' of wetland,you must first notify the u
Barnstable Conservation Division at least one(1)week prior to beginning.
Q HEALTH/WP/PERCFORM
DEEP OBSERVATION BOLE LOG Hole# .'-
Depth from Soil Horizon Soil Texture Soil.Color Soil Other
Surface(in,) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.° ..
C//L Zo 11 5�n 4Gewr /® `yam
zt (od 'C M-d«. said /o Y/2 S8
lab s=/Nr1'� "C Me e%v.t 1.�,! /'0 b'l� .7/y' o -e4sbe� m 6/c/ sM.
DEEP OBSERVATION.HOLE LOG.. Hole# Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.). (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
y'e 6/y
DEEP OBSERVATION HOLE LOG Hole# 3
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
!st' Sa L ouw� /D Y/1 `/N `
96 n (o(o" C, 1'NccQrt,,, SoHrQ /o yJ2 /(,o
��''-rtry`' CZ MoaLum Sofia to yn b
N HOLE
LOG Hole#
DEEP OBSI;RVATIO
Depth from Soil Horizon Soil Texture . Soil Color Soil Other
Surface(in:) (USDA) (Munsell) Mottling (Structure,-Stones,Boulders.
Consistency,° Gravel)
G_ s ii � ja:r8/ . awl /b `�/ 47.j
5''�•_ �SU 1� Ssnd3 Loa►w� /O YtC V�S'
Ib t2
1`I r, CZ M«f�.,„ $uR� fb W12 7/y
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes X_
Within 500 year boundary No Yes
Within 100 year flood boundary No'2�- Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification A
I certify that on �1�ii/�g�« (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described iri 310 CMR 15.017.
Signature Date
Q:H EA.LTH/W P/PERCFORM
Commonwealth of Massachusetts 1tylLI) r 11S_
�9 p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
:0
98 Sylvan Lane
Property Address
James Crocker '
Owner Owner's Name
information is ?'
required for every Cisterville V Ma 02655 5/16/2019
page.
City/Town State Zip Code Date of Inspection
CC,
Inspection results must be submitted on this form. Inspection forms may not be altered in any
t.
way. Please see completeness checklist at the end of the form.
_• Important:When filling out forms �A. Inspector Information 4P
on the computer, Sean M. Jones
use only the tab
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.: •
74 Beldan Lane
Company Address
Centerville Ma 02632
Cityrrown State Zip Code
508-658-3456, 774-248-4850 SI 4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
5/16/2019
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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System(Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 98 Sylvan Lane Osterville is served by a Title V septic system consisting of a
1000 gallon septic tank, distribution box and 3 Infiltrators. The system was found to be in proper
working condition at the time of inspection.
2) 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
14 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name'
information is required for every Osterville Ma 02655 5/16/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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
❑ ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
i
cam, Commonwealth of Massachusetts
i9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
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?
❑ E 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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 occupancy: unknown
Date
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
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 below):
3. 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:
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
f
Commonwealth of Massachusetts
ip Title. 5 Official Inspection Form
ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
system repaired 9/29/1993 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron' ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leaks or blockages. Vented through roof
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
r
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Cisterville Ma 02655 5/16/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. 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:
1000 gallons
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2"
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
11"
How were dimensions determined? opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
I
Commonwealth of Massachusetts
�a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osteryille Ma 02655 5/16/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. . 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.):
8. 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is
required for every Osteryille Ma 02655 5/16/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
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 was level and in good condition with no rot. Water level was even with outlet invert
with no signs of past backup.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
n �} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�r
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3 Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ -leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
I '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Cisterville Ma 02655 5/16/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching facility was video inspected and found dry with no signs of past overloading.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materiafs of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
caA-� I
0 1
v41 366 z
bt 32'6 93
AZ 3b
132
A3 LN b
(33
t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
98 Sylvan Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. 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
❑ ( tt g 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:
Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
98 Sylvan.Lane
Property Address
James Crocker
Owner Owner's Name
information is required for every Osterville Ma 02655 5/16/2019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
MAR 2 5 2003
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
+` CERTIFICATION
Property Address: 7 g Sy 1"12 r r,
Owner's Name: J;�wt i SA iel s
s. MAP _
Owners Address: /v .e
A PARCEL
Date of Inspection: 3--11)1�1-A_3' LOT
Name of Inspector: (please print) 10/+h 19 9a
Company Name: 1olin 94 IT, 13,.ck4�s� Ser✓�c P
Mailing Address: /;f2 N/ 9" Sr,
/I/4 >7,v+S A4,11 s
Telephone Number: S'D$ -y:g- 7774_
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 to Section 15.340 of Title 5(310 CMR 15.000). The system:
//Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority ,
Fails
Inspector's Signature: G� � 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.
Notes and Comments
"This report only describes conditions a.t 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
I �
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT- OR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
1
t f
Property Address: 98 S J"Al j4tih4-
Owner: -T,--,, z
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete'aN of Seaver. D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
•A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout 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
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
t SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM
PART A.:
CERTIFICATION-(continued)
Property Address:. y� S �v�h h ati.e
sTr�i f111217
Owner: p 1 i 1.6
Date of Inspection: 3-14/—03
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health and Public Water Supplier,if an determines that the
Y ( PP � y)
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 of 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 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. 'Y*F
3. Other:
s KKT
3
1
j
Page °
a e4 of. , .
OFFICIAL INSPECTION FORM-NOT;FOR VOLUNTARY ASSESSMENTS . x.
. ..i
SUBSURFACE SEWAGE DISPOS"SYSTEM:INSPEGTIONYOR1v ""
PART A
i
CERTIFICATION.(coatinued)
Property Address: '8
11 r
Owner: .Tk""t i-f 166
Date of Inspection: 3--2 4/—0h
D. System Failure Criteria applicable to all systems:. .•..�,
You must indicate"yes"or"no"to each of the following for all inspections!�
Yes No
_ _v Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
r/ 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'Ievel in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
v Liquid depths in cesspool is less than 6"below invert or available volume is less than''/:day flow
_/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_v 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.
v Any portion of a cesspool or privy is within 50 feet of a private water supply well.
t/ Any portion of a cesspool or privy is less than 100 feet but greater than'30'feet,frora private water
supply well with no acceptable water quality analysis. [This system passes if theAv l 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 ppm,provided that no other falb=criteria
are triggered.A copy of the.analysis must be attached to this form.] ;
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.
F i
E. Large Systems: .i 'i.
To be considered a large system the system must serve a facility wrath a design flow of.10,000 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 crit a above)
f
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.
i
i
4
Page 5 of 11
.• OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
PART B
`CHECKLIST
Property Address: 9� S �vati G•�n
Owner: T ,,Is
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
V _ Pumping information was provided by the owner,occupant,or Board of Health
1/ 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 f SAS)on the site has been determined based on:
Yes no
V _ 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)J
w
5 $
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR)rbi�NTAR-Y'ASSESSMENTS ,
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION "
Property Address:
ry I/e N 17
Owner:
Date of Inspection: 3-1`/- 03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#`of bedrooms): "330
Number of current residents:_/
Does residence have a garbage grinder(yes or no): /Vc
Is laundry on a separate sewage system (yes or no):Ve [if yes separate inspection required)
Laundry system inspected (yes or no):_
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): �00/= 106 c� )C�ouz = /o/
Sump pump(yes or no):_,�yy /
Last date of occupancy: ",r �
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): Qpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe): '
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): �j
If yes, volume pumped: o� w gallons--How was quantity pumped determined? > Zt o{ Tlk
Reason for pumping: ..74 fylC'-)H
TYPE OF SYSTEM
vSeptic 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 currant 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 com anent , date installed((if known)and source of information:
� � q�29- 93 T.�vn Rico.-�'j
Were sewage odors detected when arriving at the site(yes or no):No
6
f
Page 7 of I I
OFFICIAL INSPECTION FORM'—-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' '."PART C
SYSTEM INFORMATION(continued)
Property Address: 98 "Ift
P Y
Owner: i741n1 e) *e s _..._.....:..._.... __ ...
Date of Inspection: 3•-�`l—03 : ::<.:3,:;;:_.:,. !� ,.,a�i
BUILDING SEWER(locate on site plan). . .. . . ...:4'sr :; • r:::1 �'� . - ;1`-
Depth below grade: 2
Materials of construction: cast iron 40 PVC other, (explain):
_ _
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
f ilk
SEPTIC TANK:_(locate on site plan) !;; ::, ,,r;,�.;.,{; r.;;': ^i=, :i:•1:;i { ;:. '.'•
Depth below grade: }} ;:.. . . .:'' ' r
Material of construction:.. concrete metal fiberglass of eth lene ... . _ . _... ..,,.,.' .
g _P Y Y ___._.......__.._. .____._.._other(explain)
If tank is metal list.age:- Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of .
certificate) ,
Dimensions:
Sludge depth: y
Distance from top of sludge to bottom of outlet tee or baffle: `o
Scum thickness: gr 'l 11 c !`, {!'r: ?'.1�9 ')sI:SJ:;... ..,,� 1 � "tril's .Jlu :....l ?! Y,�Cf ll".Pi 1;t 7)r•7r:fi:Ct
Distance from top of scum to top of outlet tee or baffle: `_"
Distance from bottom of scum to bottom of outlet tee or baffle: /y'
How were dimensions determined: wc(
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels .
as related to outlet invert,evidence of.leakage,etc.):
r1 vL as oulksfi A.e.e
9ao� b u/l-�' •
•__... :\•t.d!•?i)).ib'I ii'�?�7;!�1�;0••1/nl r;Ci'11S1�1..
GREASE TRAP:_(locate on site plan)
'd lf,".r;� :vl' h!; .a 1: .Qli•!'.{:{� r�(i: �v'�;1:;):!i 7.,.lff){i:rtl•
_.Depth below grade:_. . . __.... .. ...:.,.:.:..,_.. _....:...._. _.................. ... .... ._....._ .....__ . ..._ ...... .
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:
Comments(on pumping recommendations, inlet and.'outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): .
Page 8 of 11
::OFFICIAL INSPECTION.FORM:.-:NOT'.F. WRYOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPQSAL..SYSTEM.&SI'EC-nON FORM: .
PARS'-.C: .
SYSTEM INFORMATION(continued)
Property Address: 9 wuti �ar�-e
Owner: is 54407J,
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of site plan)
Depth below grade: .
Material of construction: concrete metal..- fiber lass of eth lene other ex lain
$.. _p Y Y ( P )
Dimensions:
Capacity: gallons
Design Flow: gallons/clay
Alarm present(yes or no):
Alarm level: ' Alarm in working order(yes or no):.
—
Date of last pumping:
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: a'
Comments(note if box is level and distribution to-outlets equal,any evidence of solids ca.rryov_er,any,evidence of.
leakage into or out of box,etc.): y '
P�RfI��. �'be���..�Qs D-�oll (�G1 I :f./ • �4i�✓1�. �� w C/�l-Role /o C&P4-
.. .. .. .:..... '.:.::. .... .':rig
.. . .. .... . .. .. •A..
PUMP CHAMBER: (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 ofpumps and appurtenances,ctc.k
8 -
f
— '.Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: 9 9 5 /..G-.7 �N H e
trv� o114)7
Owner:_ JuvY►ts -5h.00ofs
Date of Inspection: 3--2 y-v3
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain Iwhy:
Twn or ih to S�ucvs ��af ,3 lhA"jthktrt
-- wirc lhsta ..I $ cam.+-,al,icI (>g�Gd 9-?9-93
Type
leaching pits,number: '
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.):
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions: ,
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
j T
Page 10 of 11
OFFICIAL INSPECTION FORM—N FOR VOI: WAIAY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAY;SYSTEM INSPECTION FORM
I
PART::C .
SYSTEM INFORMATION(continued)
r'
j11 .(
. I
Property Address: f? S Ivays
S v! ✓
Owner: fA,*"as S -414
Date of Inspection: 7nr'-24/-e3
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 here public water supply enters the building.
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Page I l of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
-•_,:';.::`SUBS,URFACF,SWAGE DISPOSAL,SYSTEM INSPECTION FORM .
i 71'.�'•l .�. •~'' •' ..
PART C
' SYSTEM INFORMATION(continued)
Property Address:
Owner: Urye".tf
.: Date of Inspection: '3--2'>—a3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 2s, y feet
Please indicate(check)all methods used to determine the'high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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)
V Accessed USGS database-explain: 16/V f nf
You must describe/how you established the high ground water elevation:
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d t .ekAcC w:, cr C•a`rHr B Gl?vd:r,.,
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TOWN OF BARNSTABLE
LOCATION 0 SEWAGE # 93 _/. -
VILLAGE d 5 ASSESSOR'S MAP & LOT ' O f/ S
-12
INSTALLER'S NAME & PHONE NO. 67,o, - S -`�SeO
SEPTIC TANK CAPACITY /0C2 d
LEACHING 3FACILITY:(type) )7 � �� e)
?�7
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
9
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
ll 1
60
>7 a o o
�, x 114 °r`
TOWN OF BARNSTABLE
LOCATION . ��/ //fir! `j /tj,zh SEWAGE #
VILLAGE d '5 ASSESSOR'S MAP & LOTI
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 3 �7 �At—
NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No... — l! Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
APPROVED OA R® OF HEALTH
Barnstable Conservation Daparune>�
� _�OWN OF BARNSTABLE
4...C`- S� ,� ltrtt t f` �ur Alt►i r11 1 JT
Work,i Tilt itrurftnn "motif
Application is hereby made for a Permit to Construct ( ) or Rcpair an Individual Sewage Disposal
ystem at: it ffe
Lo n-:\i Ss/ l or Lot No.
..
o
O cner r Address 1 t
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 ( )
d Other. fixtures ---------------------------------------------
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........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�Z. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•--••••...............•----•---•--•-•-••-•••--•••-•-----••-•-•••••I--••.......•-•-•--•-•-•--•--•--............------........••-----••--...........---.......
0 Description of Soil...................................................................................... ---------------•-------------•------------------------.......•••........._.----..
W •-- •-------•---------------------------
U Nature of Re 'rs or Alterations—Answer when applica -------------------------------------------------------------
ble. .- . ...frw.. �5.•.•�'- ?.- ��-
Veement:
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 Complianc�has e issued the board of health. g
Signed ..� ......................... .......
g ✓% �...................
I� Application Approved By ----------------- ...�:�>
Date
Application Disapproved or the o low�sonf: .................... ............... ............................................. . ................_
PP PP f f g ........................
. ..................................... .......................... ....... . .. .. . ......._.. . .... .--.................................................................. ................................. ....
qe- Date
Permit No. ........... Issued
Dare
�.--"'.i�¢r�+a:r:'`tf:^kP>"'.`r."`7�1`v+,•Klrt.�+-���^�w-w �-.:�r' r • � ._.r,..._..,M„�,..�,.,,;;��,.:�'o-a`..�-....�
t
cc�� 0 o
No.---1 3;-Y�•�• Fas..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_2 Y TOWN OF BARNSTABLE
� Appliration for Diripwml Wurkii Tonutrnrttun ranfit
Application is hereby made for a Permit to Construct ( ) or Repair) ae`n Individual Sewage Disposal
System at:
--..... :. . : ..... :... ........ ...... 1
!. ,. (^ ................... ..........
P q............ t-ion /t� )
or Lot No. I
------•--- --•••-•-•-------------•-•-•-••-.•-•---..._.....--••-.. --..-- ---........••....
Owner C Address
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther Other ' Type of Building _______________•_----._--___ No. of persons----_.-_---_•__-.-----..---- Showers ( ) — Cafeteria 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.
3 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. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:14 ......•••••--------------------•-•••••••--•--••--•-••••-•••-•••--••••-•-....._•----•.._.........-•--.........................................................
0 Description of Soil.......................................................................................................................................... .............................
x
V
W ...--•--------------------------------------------------------------------------------------------- ----••••• =--Z...................... -
U
Nature of Repairs or Alterations—Answer when applicable.- ��___f--�./:_._.__��.�.�.__�?...................._____________
4gxeement:
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 b'�eessued ,y�the board of health.
aSigned .... ..- .. .- ....-../��/.�1 -�.- .................... , ........ .
Application Approved BY ................. . .............................................................. .......--.....Date
. .-... Zj
Application Disapproved for the. 11901wing reasons: ................................................................ . ................. . ................. ......................
............................................ .................
--........ . . .... . .......................... . . ... ........................................ ........................................
ec,, / Date
PermitNo. ..... 1....-.>..<- L I ..................... Issued .....................-..........................
..--..-............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
I1LPrtifirate of (11'a Alin-nre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by .......... .. .....- ----------- -------------tall.........._.........-------------...................._..- ...........-.......-..._-----------------------.-..----
. , �e , r................................. ..............
has been installed In accordance with the provisions of TITLE 5 of TheState Environmental Code as described in
the application for Disposal Works Construction Permit No. ...---...-/..-- - .: 7_I(_...... dated .....--_.........._................_..:.-.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
cj �.
DATE - _... ..- .1.-_/ ..._....._._:_..... ---- Inspector ........._.. ...:-,.I - _.... ...........
— asCOMMONWEALTH—OF MASSACHUSETTS
BOARD
THE � � �/
BOARD OF HEALTH
TOWN OF BARNSTABLE Q
No....1. ..... (! FEE... ..................
Bispnual Workii Tonotrurtiun rrrmit
Permission is hereby granted___ ''� ��—>.f_ ..........................................................................
to Construct ( ) or Repair (li) an Individl,}al Sewage Disposal System
atNo. ,•_" ��` ��� y/^ 1 1 .................................
Street
as shown on the application/for Disposal Works Construction Permit No.-t9_?:__5."i/. Dated---_-_�.
� Board of Health
DATE............... L.-�k = 3.................................
FORM 36508 HOBBS at WARREN.INC..PUBLISHERS