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0504 FLINT STREET - Health
� 504�FLINT ST, MARSTONS MILLS �A= 101-011 �f 5 Town:of Barnstable � P# Department of I2egnlatory:5ervtces f Pubi c Health 641S<on Date tom+ l 200 Marn Street;Hyannis MA 02601 Date Scheduled Time' .: Fee Pd ►Svid Sura$ zty�4sessment far Se z osaO d � Yerfcnneds} witnessed By a�iY S . -� P tA/GATIUN&GF.N IN QRMATION i/ lucauon Address 7 i f L�j# ry� Owrie2s Name l ly� A,s 3 �147CS � Address:-S L . Asse3sor5MaplFareel ������� FngineersMamO �>;�It� i'"',j NHW COWSTRUClTON REPAAi xa-0 orn e° - f .-" ,.... 1.$nme.... Slo}xs�/��._... _. ._.. $11TfflCe$Wne3•:_: .._ _ Disfaoces f vrii: " water, R:r Possible Wer Area A g�Y Ilrmking Weter Well DranrageiSctq _ R, .Ymp"ertyLire M: ft Other ._. .; ft' SKETCH'(StCeei naafe:dtmensrons`�Iot exadtoeations oEtest,holes&Perc testa Ioge wetlands in'proximitym holes) " z .�M K �Farentimtedal(geologic) .,' Depth io liedrodc . .. De�ltto('aouydwater SSatrfiagWater,inHoie. Werprt�fromPitEace.______ .Fatiimted°5eaxonalFGgh"Grvpndxuter �� y2DETERMINA'I IQN�o FO:R SEA Sf3NAL HIGH wATE,R eTABI;E.y Ijepth Obseitved.tending in'obs bole'. io. Depth to§oii tnoules: ih, thl¢ti to uveeptng:fioni side o#obs tale in. G%tmdcvater Adiustmert Rs _ Yndex well# Rea iingllate Ltdex Well levef Adj.factor;- Adj Crtoundwater C eel ;;x �x ,, r.: %Y tip:, szP •'tee $..��r PERCQLATI4N TES? - Dar« �e Obs6vanon a rttw Depth of Pere mat, StaitYresdal Said Yresaek Rate tvfia./L+efi� ^� , • Site � � Passed ', �.� ,•.. SutteFtrLty Assrs�enti• Srte P . Srte'a!W Additional Tesdng Needed(YI1 T) Origroal Publii ticahh ihhsion Obsetvaton;Flole Data Ta Be Completed on-Back Tf area , H;. * p la#on testis to be condueted,witLin 106 of wet3and,'you must 6rst`nutify the )3arnstble.Conservation division at teestone`(1)week;prior'to beb nning.• Qu�l�xchYoxl�tDoc r x s ; . � ;3' P©BSE1t YATl01iI�!I HOLE LOGS Hok# Dgpth from_ Sot?TTatzon Srnl Texnue W Color Soil Other II SurfI'll o) Y (USDA} {Muawll) 3vtoH7tng (S6uctgre Stone Bouders- , r< r .. , - _...� �r .�, - S x- Y 9 DEEP OBSERVAT ON:IHOLI LOG a, Hole#° '> p. S _.... $ ;.,l ,. De As from 3oit tl6hzoa - I 30'! e-thi a Sod Color Soils.. -..' Other - ' ' SurCoae{fit.) (C7SDA)' m,, (Lviur'sel�' AtaBlwg (Strtichue,'Stones,-"Idern. 1 . .- ,;,., .. '•Dons' t'm+voll - - +,; � ... tslmt�3, . ' .: _r_ . x�, y ham_ , II .. �_� ,, ..: Z" DEEP QBSEIZ'(?ATL©N ROLE FLOG Kok# - ,'&W DepthtYom SoctHorizon ".SoilTexw*e =$Oil Color 3oit Other ; e,(ut)'- (USDA)- (yturxe. Mottling {SV+�cluz Stone%Boullde's; �. rI ,,, .. I. ,,:_: n ' b1✓EP,OBSERVATIiOIY'�H t t,OG ` M dole# ; m Detith from 3oit Horizbr - 3otlTe dare Soi!Color, 3o'`} Ottxr ,Surface.(iti.) (L73DA. :: ) (A4uaseil) Mottlin (St?ucnuc Stones,Boulders '. ;a - a�mnakicec°l''C.4� r > ., .. .. . ,l+Iood Insnran#e:Rste 11�an.< M s- Above590yeaioodboundmy, No Yes Wtd nSnOyear2 iundary No YesI .. Withn100yesrnood,twtiiedarg Np Yes & k . ,, „„ „ ,..,., ;Tle»t6 afNatarAi( .Icarnag P.ervrous 1►$atejai..` , Does at Ieastfottr feet of natt>salty ocgutring pervta»s,material ext5t to all,areas observed throughout the ,I- 'MrIproposed£or the soil absorption§system? If"not,what is the d th of natural occurm otts material? eP �Y &Pam. 4..: y ' : •^CCttltl�tiOH- ' I ccrttlythat on (date)I ltaye passed the sol7 evaluator examtnatton'approveti by the Dement of Etivlronmer%ta3'P.rotecnan and that the%above analysts was"performed•by me,t onslstent witb ttietegtured trnmmg eXpertise;aftd experience ile nbed to 3I0 CIvIR IS.OI7 W Signature 17ah ,. rr,a- r . ' ,. , . , .,.. .,a Q`$EPIIGIPERQ'ORM DOC w _.... , d r No. FeeJ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye_ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppricatiou for -Misposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(v�Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No.,5044 I VI S$ Owner's Name,Address,and Tel.No.ZgC1,0,r1j fg4CDDf— Assessor's Map/Parcel 'p I - ) I Installer's Name,Address,and Tel.No..8 AP B EXCOAAX- tOA Designer's Name,Address,and Tel.No.W-«;.t ICAVI O-RMA' t4Tca,Sc-rr4 LOIJ Forcmm-wc qrn-ozS Po.SoX 81 �<XrMov}k foes Type of Building: Dwelling No.of Bedrooms Lot Size OS'730 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ZZO gpd Design flow provided gpd Plan Date '7- )$_ )9 Number of sheets 7Z_ Revision Date Title Size of Septic Tank /000 Type of S.A.S. SOO qcj L-�C- Description of Soil Nature of Repairs or Alterations(Answer when applicable) -JD .BDX- Z L)c SOD ck o_kn xs Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. r Sign Date �. Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Lo (� �(� Date Issued No. Fee •� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS-* Yes 01pplication for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair(%/Upgrade( t,,�Jan�lon( ) ❑Complete System ndividual Components Location Address or Lot No. 50 y R;/Ij Owner's Name,Address,and Tel.No.Zqcl,a r y m a Ic DOna lol Assessor's Map/Parcel �0 - I rJ�� M` 10 pq F l I,\A $4 y Installer's Name,Address,and Tel.No. EXC,s JL ►0N Designer's'Nanie;Address;and Tel.No.Ff,k r-ri f ro,--z 1LJ—rr_a.Sr_rrLj LIQ F-or �iQl l�. y11'06,5 PoSox $I h�ar-� Type of Building: Dwelling No.of Bedrooms z., Lot Size /,T 730 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided g gpd Plan Date '• 1 S- )IS Number of sheets '�„ Revision Date Title Size of Septic Tank 1000 Type of S.A.S. SOo q a 1 L_j(Z. Description of Soil 4 i i Nature of Repairs or Alterations(Answer when applicable) ,Q®X ^ Z. L1 C .J 0Q(Z k a 1'l,5 Lr,$ F Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. , Sipe 9 Date -7 1 L ) I i Application Approved by Date Application Disapproved by � Date for the following reasons Permit No. 2 o ( , ,2 / 6 Date Issued 7 4 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by 3 i-.Q ExCQk),mA 10✓\ at Sp n.n 1 5-1 0 M; )I:5 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _?0 -z f 1dated -7//4 /j Installer 3 •+ EX Ccx 1 0 Designer ( V c0hcP t..� #bedrooms Z,. Approved desig ow gpd The issuance of this permit shall of bye+construed as a guarantee that the system wil fimctio d si d. Date / � D Inspector No. r O( b Fee Ud _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( %e Upgrade( ) Abandon( ) System located at SOY F1 54 rcy_--I d) M; 115 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must be completed within three years of the date of this permit. /� Date /i Approved by 11tru per i Town of Barnstable 0p1HE Teti Regulatory.Services Thomas F. Geiler, Director MMUqSrABLE, Public Health Division Thomas.McKean� Director FO MA'S -200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: "1-Zo- 1$ Sewage Permit# 2018 Z 11, Assessor's Map/Parcel /o/ -I 1 Installer & Designer Certification Form Designer: Installer: icy'. Address: p, Box S 1 Address: I� Teo�et-c-u� LO �c�rr�o�rll��oc"1 Fo rc�S-}o�ca.l c_ On J-1 G- $ 84 Q Exeaukx4 i o n was issued a permit to install a (date) (installer) septic system at Soy S'f based on a design drawn by (address) yL F to h ee�c dated 1- 1.5-18 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distri4ution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. V I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer:to follow. Stripout (if required) was inspected and the soils were found satisfactory. DAVID vo D. staller's Si ) LAHERTY, R. No. 1211 (Designer' Signat: ) .(Affix Desig p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:office formsWesignercertification form.doc i TOWN OF BARNSTABLE LOCATION .50q Fl i n-I S-1 SEWAGE# 201 A- Zf C, �-R VILLAGE ('), (n;115 ASSESSOR'S MAP&PARCEL.101 - I INSTALLER'S NAME&PHONE NO. EXcoycLA i pn y'17r)• 1)6S3 SEPTIC TANK CAPACITY LOW $2d LEACHING FACILITY. (type) 5Q0 (size) I3 x ZS X Z NO.OF BEDROOMS 3 OWNER 7ac�,aru ���o%Ic�L PERMIT DATE: '7-11, I S COMPLIANCE DATE: '] ZO - I$ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Al 8iL4" 81 A2- , A (37. 1V 3" fB3• C3 3z,z, 0 fay zj, ` A C4- Z9�19 oa F-r onA C f Town of Barnstable P# 1 5 dp' Department of Regulatory Services :...NSTA]": Public Health Division Date MASIL t6Tq.��� 200 Main Street,Hyannis MA 02601 Date Scheduled 3 fl 2 Time Fee Pd. Soil Suitability Assessment for Sewage)is [osal Performed By: Witnessed By: 7( a) L5 LOCATION&GENERAL INFORMATION Location Address 5-0q F'101-57- Owner's Name;&�jq Y MtcaM"o MthcS tm3 N I1(s t 144" Address Sihvf .���t���� �/ Assessor'sMap/Parcel: IOI/Ol' Engineer's Name 06VIO 1^�/ NEW CONSTRUCTION REPAIR Telephone# I_ I —r t/, 140 r Land Use�)��� Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area It Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations oftest holes&perc tests,locate wetlands in proximity to holes) L��J Parent material(geologic) wt t WOO Depth to Bedrock Depth to Groundwater: Standing Water in Hole: A 01A Weeping from Pit Face Estimated Seasonal High Groundwater a 1� c DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date Time Observation Hole N Time at 9" Depth of Pero Time at 6" Iv Start Pre-soak Time Q ` Time(9"-6") , End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original:Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. QASEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consist Consistenev.%Gravel o A-- �' 34 8 10 AS- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C nsistenc %Gravel o10yr + A DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Graven BEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate May: Above 500 year flood boundary No Yes_ Within 500 year boundary No_ Yes Within 100 year flood boundary No Yes_ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perviote gal exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervi s material? Certificatiton . I certify th (date)I have passed the soil evaluator examination approved by the Departmeotection and that the above analysis was performed by me consistent With the requird ex erience described in 310 CMR 15V8118 Signature Date Q:\SEPTIC\PERCFORM.DOC } LOW N C3 CID - cfl Certified Mail Fee Extra Services&Fees(check box,add fee as appropriate) ❑Return Receipt(hardoopy) $ nS�•1Q O ❑Return Receipt(electronic) $ Postmarks?� 9- Certified Mail Restricted Delivery $ 1 r Here /y O []Adult Signature Required �� ❑Adult Signature Restricted Delivery O Postage OC�� � Total Postage and MACDONALD, ZACHARY T $ U I Sent To 504 FLINT STREET N 3i;eeraodAwfwF MARSTONS MILLS, MA 02648'-- City,"State,ZIP+4? -"-"-- Certified Mail service provides the following benefits: •A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate •Electronic verification of delivery ehaitempted s return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the;' ■A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides � for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent i Important Reminders. Adult signature service,which requires the •You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service, Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified y ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent. with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items: USPS postmark If you would like a postmark on - ■For an additional fee,and with a proper this Certified Mail receipt,please present your ._ endorsement on the mailpiece,you may request Certified Mail item at a Post Office'"for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barooded portion_ of delivery(Including the recipient's signature). of this label,affix it to the mailpiece,apply _ You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. 7 electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return Receipt,•attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. Ps Form 3800,Apra 2o15(Reverse)PSN 7530-02-000.9047 r Y Town of Barnstable Barnstable AbARegulatory Services Department cap j BA BM F MASS. Public Health Division m AtECMA�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0671 June 5, 2018 MACDONALD, ZACHARY T 504 FLINT STREET MARSTONS MILLS,MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 504 Flint Street, Marstons Mills, MA was inspected on 05/23/2018 by Shawn Mcelroy, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Backup of sewage into the house due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\504 Flint Street Marstons Mills.doc L f THE r, ' Town of Barnstable - + ARNCiIRT i•_ Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-862-4644 Richard Scab,Director FAX 508-790-6304 Thomas A McKean,CEO Feb 6,2007 Rev. 5111116 DEADLMS TO•REPAIR FAMERSYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ .An` ed ' is e ure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent e surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe, :Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis."(This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Single'Cesspool ❑Any"conditio'nally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, (Ac) b Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: _ WSEFTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form "C�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 504 Flint St Property Address *' �a Sarah Macdonald ; -; Owner Owner's Name information is Marstons Mills ✓ MA 02648 5-23-18 required for every " 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. A. General Information s7o 13cqi- 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.600).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-23-18 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 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 y Commonwealth of Massachusetts - 3 Title 5 Official Inspection Form w: r.rt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5=23-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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 Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5ins.doc•rev.6/16 s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts r� y Title 5 Official Inspection Form ,ibi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ , ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 4 of 17 f Commonwealth of Massachusetts y Title 5 Official Inspection Form ' I Subsurface Sewage Disposal System Form Not for Voluntary Assessments .: 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any'portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. , Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts ;w Title 5 Official Inspection Form i�i Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 504 Flint St T Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? E . ❑ 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? r , ® ❑ 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: r Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 5-23-18 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts •- Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' - - r4 '``' 504 Flint St'L7 .�..�� ,. =:=r- Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town 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: Owner--pumped within last 2yrs Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ - Shared system (yes or noj (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): i t5ins.doc•rev.6/16 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form C�ll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s: ? 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness - Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? I Tape 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 is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): imen D ins so . Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts r� y Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y w� 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 c Commonwealth of Massachusetts iw. Title 5 Official Inspection Form i,l, Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 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 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.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in'working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts r7 y Title 5 Official Inspection, Form Jai 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-Infiltrators ❑ 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.): Infiltrator field was filled beyond capacity and into sewer line. Cess Cesspools p (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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form I> Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .Y, 504 Flint St r Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) : . ' Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >' �e•a:,_•F,, 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately .. .. . a I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments > 47 " 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is Marstons Mills MA 02648 5-23-18 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used t d o determine the g high round 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 .,� Commonwealth of Massachusetts f1a Title 5 Official Inspection Form Iwo' r�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 504 Flint St Property Address Sarah Macdonald Owner Owner's Name information is required for every Marstons Mills MA 02648 5-23-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. 367 Main Street, -*� � Fill in please: Date: CCJ I 0 ' APPLICANT'S NAME: y,� � � per^ Tl YOUR HOME ADDRESS: ti /�tiS fV-•S /�C` 17 854 � BUSINESS TELEPHONE # 5d&.- 31 �_ 8d7S HOME TELELPHONE #: SaK- 3C,It ttS NAME OF CORPORATION; - - NAME OF NEW BUSINESS_ er cow e X TYPE OF BUSINESS . v( IS THIS A HOME OCCUPATION? ✓" - G� S ES NO ADDRESS'OF BUSINESS. SOL�t iFFI. •T S�— MAP/PARCEL NUMBER; (As'sessing) When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of Barnstable. This form is to assist you in obtaining the information you may need.. You MUST GO TO 200 Main St. (corner of Yarmouth Rd. & Main Street) to make.sure you have the appropriate permits and licenses required to legally operate your business in town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. COMMENTS: Authorized Signature** 2. BOARD OF HEALTH This individual s een i f r d of t e permit requirements that pertain to this type of business. 70 Authorized ignature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: i YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates (cost $30.00 for 4 years.) A Business Certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.I.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. Fill in please: Date: 5 -�-c u" APPLICANT'S NAME: St017 �"�a•• p _ YOUR HOME ADDRESS: 5a6 ' - BUSINESS TELEPHONE # HOME TELELPHONE #: i NAME OF CORPORATION 1 I NAME OF NEW BUSINESS !qPC p TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS MAP/PARCEL NUMBER-: _ (j� (Assessing) When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of Barnstable. This form is to assist you in obtaining the information you may need. You MUST-GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to lega opera a ur business in town.- 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. �. � Authorized Signature ,. COMMENTS: ' 2. BOARD OF HEALTH This individual ha en in rmed h e=itCremt at p a n�o this type of business. ut orize8 ignature COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature" COMMENTS: COMA'10-V E_4 TH OF 'T r �SS �HLSF� E-Ecur _cT 0 ,7'l I A OFr t F Ev\ZRO\'_JF_TA1 _ I^ DEPARTMENT OF E_,\T1R0NTXTE\T_:T PROTFCTT� t= i col 0// TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNT-ARY ASSESSA ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 99 Property Address: -S o Lf,�41 Owner's ame: `� /1�� /V"4 !zi✓'oi Le,X- /..��,//ocher Owner's Address: /O Date of Inspection: /p 0A6 Name of.Inspector• ( lease print) Company Name: iVV1 p — 4-- flailing Address: O L qs Telephone Number: o � °Z zi ` CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that then �:aro r0ne. below is true, accurate and complete as of the time of the inspection.The inspection was�erforme : ^ased training and experience in the proper function and mair_tenance of on site se;vaQe di r --F .��?osat s�:ste~ . � am a�+r_� r., approved system inspector pursuant to Section 15.340 of Title 5(310 CN R 15.000). Tne s.s ~. a_ t'+'t [�passes Conditionally Passes Deeds Further Evaluation by the Local kpnro;:a Fails Inspector's Signature: Date: /a The system inspector shall submit a cope of this inspection report to the Approving Awt o :f Boa_d`= DEP)within 30 days of completing this inspection.If the system is a shared system or has a deci?r"� gpd or greater, the inspector and the system owner shall submit the report i to the a jx n ,=�i,� l ., The original should be ser_t to thep _ p _°p`ya`= `�" system owner and copies sent to the buyer ;f an,lica'_?e. and-- DEP. authp ty. — _ . sel",�Ic Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of u:e at t"12t 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 l l OFFICIAL INSPECTION FORMM—NOT FORTrOLLT"N-TARY ASSESSMENTS SUBSURFACE SEkNAGE DISPOSAL SYSTEM INSPECTION FORM A f CERTIFICATION (con-Li led) Property Address: Soy I/ 7 s Oo rner: 1—Q X— N / iu c Date of Inspection: Inspection Summary: Check A,B,C,D or E!ALSO AYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure critera descr_bec 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated b :o Comments: B. Svstem Conditionally-Passes: A/One or more system components as described in the"Conditional Pass"Section need to b;,� replaced or re aired. The system upon completion of the replacement or repair,as approved by the Board of Heat '' =. f 1 1a state r 7e Answer yes, no or not determined(Y;\,\�D)in the for the e_1o��7._�state�..en's. I�"r_ct Ole_e�--='� ea�� a-.. explain. The septic tank is metal and over 20 years old,or the septic tank('whetae-metal or nct) s unsound. exhibits substantial infiltration or ex0 ration cr tank'ailure is SyST e_ _ existing tank is replaced with a comphing septic tank as approved bv,the Board of Health. *A metal septic tank will pass inspection if it is struct'arally sound,not leaking and if a Ce;i _Cate of Co -r:-titre= indicating that the tank is less than 20 years old is available. N7D. explain: Observation of see;-age backup or break out or high static eater level in the d:stnburion box due 70 br0 err. or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System,v ili pass approval of Board of Health): i broken pipes)are replaced obstruction is remo old distribution box is leveled or replaced \7D explain: The system required pumping more than 4 times a year due to broken or ebs-acted pass inspection if(-,vith approval of the Board of Health): broken pipes)are replaced obstruction is removed explain: Tirlo �incr+orti�.•. L'„-,,.. �/2:!'�nnn � Page 3 of 11 OFFICIAL INSPECTION FOR.ANT- NOT FORS OI.LITAR_- ASSESSMENTS SUBSURFACE SEWAGE DISPOSAZ SY"STENI INSPECTION FOR-N.i PART A CERTIFICATION;continued) Property Address: G O Owner: J eX _ -1//o col Date of Inspection: 0 C. Further Evaluation is Required by the Board of Health: /y Condirions exist which require further e�,aivatioa by the Board o`Heal:h it order to des=_7 ii e is failing to protect public health, safen or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303,I)(b) that the system is not functioning in a manner which Rill 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 sal;marsh 2. System will fail unless the Board of Health(and Public Water Supplier. if any) deterrrdnes that the system is functioning in a manner that protects the public health,safest-and en-,ironment: _ The system has a septic tank and soli absorption system(SAS)and the SAS is j.�i1�1, '0� f 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 uublic Waters The systern has a septic tarp and SAS and the SAS is within=0 feet of a rri-:ate wate-_urn'.- — The system has a septic tank and SAS and the SAS is less than 100 f er but f0 _'-et a m^_e '� o N a private water supply well**. Method used to determine distance "This system passes if the well water analysis.performed at a DEP ce.rified labor ato ; on bacteria and volatile organic compounds indicates that the well is free f om aollu cn c t-at the presence of ammonia nitrogen and nitrate n trogen is equal to or less than u nr - failure criteria are tri'gered.A copy of the analysis must be attached to this form. 3. Other: Tirl. jncnn�t�nn �,� I Page 4 of l 1 OFFICIAL INSPECTION FOR17-1lOT FOR VOLU'NTA_R _ SSE, ,1jE_T; SUBSURFACE SEWAGE DISPOSAL SYSTE-II i1SPFCTTC►N F®R-kI FART A CERTIFICATION (continued) Property-Address: ..So Fli h Qsv net: Le x rs c1 O Date of Inspection: / 0 9 D.6 D. System Failure Criteria applicable to all systems: You must indicate "yes" or"no"to each ofthe foilowin2 for ail inspections: Yes \o _ � kup of sewage into facility or system component due to overloaded or clo=-?ed S_ S or cess-oo: _ v Discharge or ponding of effluent to the surface of the n y - , _,ace -rou_.d or surface�;-at= �ogged SAS or cesspool V -s — Static liquid level in the distribution box above outlet invert due to an overloa ed c..`:, _ S_�S e- sspool `-- _ depth in cesspool is less than 6"below invert or available volume is less t an = day f,c,. Requi ed pumping more this.4 times ir the last near\QT due to clogged o7 chin ted times pumped _ y porcior of ne SAS7 cesspool or pr.v),is belo n high ground water eleva ion. Any portion Of CessDOol or privy is-,vithin 100 feet of a surface water supnh or r_outa '.-to a s r 2ce �-ater supply. - - _ - portion of a cesspool or privyis within a Zone 1 of a public well. A i po:pion of a cesspool or priory is within 50 feet of a prvate water supply Any potion of a cesspool or privy is less than 100 feet but greater Char 50 feet from a v are-.;eater supply well,.with no acceptable water quality analysis. [This system passes if the well --ater 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 i ppm,prop ided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.' Z �(Yes/'1Vo) The system fails.1 have determined that one or more of the -, -...e above described in 310 C1'1R 15.303,therefore the system fails. The systern ov,-lei s-hou c ;on:ac t-e Board Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must sen-e a facility with a design flo-w of 10.000 gpd to 1;.000 gpd. You must indicate either"ves"or"no"to each of the folowin2: (The following criteria apply to large systems it addition to the criteria above; y s no e system is within 400 feet of a surface drinking water supply the system is vv t m 200 feet of a tributary to a surface drinl;n2 water sunnt the system is located in a nitrogen sensitive area(interim��.elthead Prc;ec�n- Zone II of a public water supply well If you nave answered"yes"to any question in Section E the system' 'de red mis constd red a si2r�_ ae�s in Secron D above the large system has failed.The owner or operator of an, 1G12; ` sigrLfcant threat under Section E or failed under Section , - - . 04. Th.,system o v� r � _..2_.tp,:ad. :he Stvice-�;� � - - - - ale should contact the a�=- - appreprate reoi�rai T;ilc Face ; of:l OFFICIAL INSPECTION FORM-NOT FOR VOLL-NTARY _ASSESS-TENTS SUBSURFACE SEWAGE DISPOSAL S�'STIE`TINSPFCTTO`i FORAT PART B C-11 ECIaIST Property address: �� ���✓� S� Owner: ZPX Date of Inspection: 90,6 Check if the following have been done. You must indicate"Yes"or"no"as to each of the :olio Yes ; Yumpin,information was provided by the owner, occupant, or Board of Heal-! 1 ere any of the system components pumped o, h - p p p it in the previous two ;,•-eo-�cs ., 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 roar: FTh-'s ;-:-;,c- Were as built plans of the system obtained and examined?(ff thev were not available note a_\A) Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out`? �VV ere all system components.excluding-1e AS. located on sit-, VUere the septic tank manholes uncovered. opened, and the '-=e- r off he T - _— P zi�.,.L�o_ �. -r... -�:� of the baffles or tees; material of construction;dimensions, depth of liquid; dep'7 of slud_e and deroth of s.u-._ : Was the facility Owner(and occupants if different from o«rerj prop ded�=.,t y:. =o_rn�f or an --over maintenance of subsurface sewage disposal systems T're size and location of the Soil Absorption Svstem(SAS) on the s to has ee ec�,, -_on: Yes no _��'sting information. For example, a plan at the Beard of Health. Deterrriined in the field(if any of the failure criteria related to Part C is at issue r -e�`: -1 10 is unacceptable) [310 C_pvm 15.302(3)(b)] T;+lo ." T..cr.ert;nee =nrr.� <.I7[17nnn Page 6 of i 1 OFFICIAL IlSPECTIO-N FOR1I—NOT FOR VOLUNTAR), ASSESS:IEN T S SUBSURFACE SE`17AGIE DISPOSAL SYSTrAl INSPECT TON FOR AT PART C SYSTEM IN FOR TATIO Property Address: _3 0 /�,,, Date of.Inspection: /p 9 RESIDENTIAL, k-LOW CONDITIONS \,umber of bedrooms(design): O�- 'Number ofbedrooms(acniai): -Z DESIGN flow based on 310 CIAO 15.202 (for example: 110 gpd x=of bedroo: p Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry or a separate sewage system(yes or no):/V,Fif es separate inspect:^,rr1c1Uire:d- Laundry system inspected(��s_or no): J Seasonal use: (yes or no):— Water meter readings, if available(last 2 years usage(gpd)): SUMP pump(yes or no): &V -Nast date of occupancy: CO-NLI IERCI-aL/I\DUST—RIAL� Type of establishment: Design flow(based on 310 CNIR i 5.20;): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary xvaste discharged to the Title 5 system(yes or no): Water meter readings, if available: — Last date of occupancy/use: OTHER(describe): GENERAL I TORINLATION SourePumping Records r(vyes Source ofinformation: �j'as system pumped as part of the inspectio or no): If yes, volume pumped: gallons--How was quantity pumped deterrnLned" Reason for pumping: y TSP F SYSTEAM Septic tank; distribution box. soil absorption system. —Single cesspool _Overflow cesspool _PriA:•Z- Shared system.(yes or no) (if yes, attach previous inspection records, if any) Innovative:'Alterna#ive technology. Attach a copy of the c,=. ent operation and mai-tenanc: c obtained from system owner) t_ —Tight tank —Attach a copy of the DEP approval —Other(describe): Approximate age of all components, date installed if'known) r ( )and source o• unforMai=en: 9 S'- �a/71 Wer=sewage odors defected When am*-vffig at the sire(yes or rc): r Pare 7 of 11 OFFICIAL INSPECTION FOR1_NJ—NOS FOR VOLL-__,N"T RY _-ASSESS:TENTS SUBSURFACE SE' AGE DISPOSAL SYSTF-1I INSPECTION FORAr PART C SYSTEM INFOR_®IATION(con_inuedl Property Address: rCF _ ✓, s� O Owner: Date of Inspection: BUILDING SEWER("locate on site plan) Depth below grade: 1� / Materials of construction:_cast iron _ 0 PvC_other(expla n): Distance from private water supply well or suction lane: Comments(on condition of joints, venting,evidence of leakage.etc.): SEPTIC TANK: —(- locate on site plan) Depth belotiv grade: I // \Rate-ial of corsmacnon:_,o�ncrete_-petal_fiberz1ass_moo?=-ehvlene other(explain) If tank is metal list aae:_ Is age confirmed by a Certificate of Compliance Gc(�2s o-no a ccp o= certificate) (yes Dimensions: _x Sludge depth: 6 // Distance from top of sludge to bottom of outlet tee or bade: 5` Scum thickness: Distance from top of scum to top of outlet tee or baffle: �f Distance from bottom of scum to bottoms o out'_et tee cr bafe._3 How were dimensions determined: %O), c✓e v/c L Comments (on pumping r=conimendations,inlet and out, tee or baffle condition, smucrural inieT- as related to outlet invert, evidence of le kaae, etc.): _ a 62`/e o oK GREASE TRAP:�cate on site plan) Depth below grade: _ Material of consxsction: concrete metal fiberglass poi,-ethvie-e "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 outiet tee or baffle condition. s7rj:-o-2_ as related to outlet invert, evidence of leakage, etc.): -� - l Page Q of Ij OFFICIAL, INSPECTION FOR-1- 1—NOT FOR VOLUNTARY ASSESS`IE`ITS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTiON FOR1t -kRT C SYSTETNI INFOkN. TATION(con:nued; Property address: F1,4- s �-- Owner: ��x — Ave Date of Inspection: /o } Q TIGHT or HOLDING T N-K: /� (tank must be pumped at time of inspecron}(iota>e o Depth below grade: Material of construction: concrete metal_fiberglass pohe-rhylene ct�.=-i Dimensions: Capacity: gallons Design Flow: calions.'day Alarm present(yes or no): alarm level: Alarm in working order(yes or no): Date of last pumping: Coy rnents (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: l-2011m r,G— Comrnents(note if box is level and distribution to outlets equal,any cadence of solids car o e-. an =nce o leakage into r out/of box. etc/): r PUMP CHAINIBER:Z� (locate on site plan) Pumps in working order(yes or no): Alamns in working order(yes or no): Comments(note condition of pump chamber;condition of pumps and appurtenance_.. etc. Titl= z,, Tn cnortinn T-- 4/1 C 7^nnn f Page 9 of l l OFFICIAL INSPECTION F'ORi1-NOT FOR VOLU-N T_AIRY ASSESS1IEN T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F()R-:i PART C SYSTEM INFORMATION(continued) Property-Address: Owrer: te Date of Inspection: /D 9le,6 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan.excavation not required) If SAS not located explain«$y: Type // leaching pits,number:_ t'7 7i1, 61 leaching chambers. number: / / leaching� ieries, number: w d Spry leaching trenches. cumber_ lensth: leaching fields, number; dimensions: overflow cesspool, number: irn(,,vativeialternati.,e system Typefname oftechnoloav: Comments (note condition of soli, signs of hydraulic failure,level ofponding, damp soil, condin of eget-=on. etc.): S� � .�,/ C0 h ti C% 4 CESSPOOLS:& cess ool must be pumped as part s n)( P _ r ? of n..pecho__�(locate on site p1.ar_ 'umber and confiauratior_: ,eprh—top of liquid to inlet invert: Depth of solids layer: ;_,epth 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 ofponding. condition PRIVY:'i (locate on site plan) Materials of consc ction: Dimensions: Depth of solids: Ccmments(note condition :&soil, signs ofhydraulic failure, level ofponding, �;rlo : Tnc ..f;.,, �i1:✓�nnn q Page 10 of 11 OFFICIAL INSPECTION FOR-,NI-NOT FOR VOLLITARY ASSESSAfENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PST C SYSTEM I FORN1'IATIO-i'(contir'aed) Property_-address:-� O y S F11-1 L- A i 76Z -.r 04 Owner Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the se«age disposal system including ties to at least'Zvo pe=nenT refertnce la^ '^ark-s o- benchmarks. Locate afl , ells %within 100 feet. Locate vrhere public water supply- the bu_ld C I , C r' 3) C�Z - 3� Tit]. T— ..t;-, I:,,, Pa_,�� llof' � OFFICIA-L INSPECTION FORM-NOT FOR VOLUNTARY ASSESS�TENTS SUBSURFACE SEIN AGE (DISPOSAL SYSTE-I INSPE TION FORA! PART C SYSTEM INFO NATION(continued) Property address: S�if FlI H rs� 0-wner: L.ex_ ��0 !✓ Date of Inspection: l0 9 SITE EXAM Slope Surface;;,ater Check cellar i /�0 Shallow«-ells � Lf Estimated depth to ground v ater 5 feet 2✓ O ?lease indicate (check) all methods used to deternine Vne high ground;w-ater elevation: ObtaineSft-=system design plans on record-if checked.date of des i2r.plan Ob red site (abutting property/observation hole vdihial 50 feet of SAS) Necked with local Board of Health-explain: Checked vv th local exca-vators, installers-(attach documentation) Accessed I:SGS database-exniain: You must describe «,you established the high arloun s a'er elegy anon: , O v'1 /✓iaT��� ri �t J H L TOWN OF BARNSTABLE LOr:AT10N SO /F/i N r sti SEWAGE # LZ VILLAGE ASSESSOR'S MAP & LOT /0/ �l INSTALLER'S NAME & PHONE NO._ gA O1 � il(�rAJOI -s 7R1 9 CON-Sto-v Ctl oq 4A - 5 05- SEPTIC TANK CAPACITY /000 g.,Q/ LEACHING FACILITY:(type) 10 (size) uN�,f NO. OF BEDROOMS z PRIVATE WELL OR PUBLIC WATER W4*l r- XBUILDER OR OW-NER V"D TE PERMIT'ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: YeS No 14 � r S ff;ole D-6dx 1 040 us loll ft zo S toNe a 1 ASSESSORS MAPAd y.--r PARCEL NO. Z Q) THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Dhnp asal Murbi, Towitrnr#inn Frrmit , Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal system a of f t�a .. ..V.-- o �sq/ s-•`--•�-1 `�s-------------- -.-.-.- --c.v..... ---.... ----------------------------- ••• rd � ! - ne t � Address - ----------- -------------------------- --/ --------•-•. �------------------- Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—Type of Building No. of persons............................ Showers g ---------------------------- P ( ) — Cafeteria ( ) dOther fixtures -----•--------------------------------------------•-----•----------------•------------...._.....--•-•---------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. 04 W Septic Tank—Liquid capacity-�A"—gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..--___-..--_-___--- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. 1_--____.-_-_---minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•-----•-------•---....----•--•--••----•--•------•-----•---•------•----•--•------...-•-••-•................................................................. ODescription of Soil........................................................................................................................................................................ W -.------`•-- --•---•-•-•----•-------------------------------•--.-.-----------•--- .................. -----...........---•- x U Nature of e airs or Alterations erations—Answer when applicable._.."�Aj-5.. 11--�___.....M-e.Kj__........�.Q_Q D____. la4 ..............•-•--- A reement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ ode— e ndersigned f rt er agrees not to place the system in operation until a Certificate of Com lance has een s e b the rd f ealth. Z Signed - _. .. ............. ..'...... -.� Application.Approved By .......... %------------------- - ----------- ...._.........-_ ..................................... ----..........._.....-------... ----....-..---- Dare .. Application Disapproved for the following reasons- ------------------------------------------- ----------------------------------------. ........................................ .................................... . ........ ......... ................... ..................................... ........................................ �J Date Permit No. c-� .. - - "9 .. Issued .......... �/�.�`.J � \ Dare -..--- Q/1 )o • .............. ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ` , pptiration fur Di-tip ial Wor1w (Sonstrurtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem at > L Location-Address o, --7 r Owner Address VI- 147 66 — a , --- Installer Address d Type of Building Size Lot............................Sq. feet U 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 capacitv_)10.Ogallons 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. 1________________minutes per inch Depth of Test Pit.-.................. Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 --------------------------------------------------------•--------•--------•-•-•----••...._----------......................................................... 0 Description of Soil...................----•---------------•._._...------•-•-••--•------------•--••-------------------•-•-•_._.-•------------•---•--••--------------------.._....---...__.. x U ___________________________________•----•-•----•-•--•-•---------•-•-•-------•••----•----.....----------------••-----•-------•--•--------•----•----------•--•-----------•---.....•---•---..._------------ W ...............................----------------------------------------------------------------------------------------------- -------................................................ U Nature�of R�epa or Alterations—Answer when applicable.__-_ t_�F ----______-4J_e"�,t...........44 lJ J_._C_ -•;.`k? ..`'�--------------------- �,,�, ...�?;�,,,11 -------- ��=��''� �.•---•--••--••--•--•--••-•-•-----•---••-•--•-----------•-•-•-•.............. Agreement: J ✓ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmenta-1-Code—Th,e undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sued byl the tiard pf rhealth. � Signed�,.` ...... ... ......,........I_,,......... ..... ._..................... z........j5 "Application,Approved B �Z------------------------------------ -------.--...--------------------------..._. Dare Application Disapproved for the following rearonr: ..... /...... ........... ...................... ..................... -------------- -- --------------------- -------------- ------------------------------------------------------------------- ------------------------------------------------------------------- ........................................ .... Date Permit No. `— _ ....�....... �a'r7 - Issued L�:. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CITertifirate of Tomplinure �IfiS fiS`1' E �Y, T at theI�rv-tdua5Sewage Disposal System constructed ( �>O or Repaired ( ) --------- -- ..y�Jy/f[�A ( '-c-'-�---- --------------r /"A /J/J ----------------------------------------------------------- by !Sy11 at -.....__...-..- � - ...- - ------.....- (�i5•.. . - .... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. �^."._... -' dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... _,, -.. / -_- ---- Inspector ----------------- --r^- --.-:------ -----------------------...------- C,._% THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH <2 TOWN OF BARNSTABLE !� �, o�- No. .......... ........ ! ' ` FEE..... ............... Fla ion rrmit x� ltrt / v Permission is hereby granted_r.�._ __- __ - ----��1/__ �.!! t�.�.�2�� _........... to Construct ( )r or,R pair ( ) an Individua �.1;2,age Disposal System Street 6j as shown on the application for Disposal Works Construction Permit No._._ ________�o�ated.._..____�_...._��__�_.-.-�l...S-_.. 9-5--- ................... -------------------------------------------------------------------- —to _ Board of Health DATE-------------------- ••---------.............................................. FORM 36508 HOBBS&WARREN.INC..PUBLISHERS - era ofV�Aa f SEWAGE# yIIFGt/S7�n s r7�s ASSESSOR'S hf ,OT 11�TA:�.LElZ`$itAl��pg{3�E N'4 SBP'ItG TA�EK CAFACMI 1 LEACf3Il�tGFACII�1'�Y {typs} `�'`� 140.opuoRoomt EtJ#I:DFR"OR O PERIVIlTDATE' Ct?MPT. NCE - Sepatat�on Distance Bet►xesti the FeEe N[a�c�numAd�ustecl GrounwaterTabletothe Bottom ofisactingFacii�ty Pmat ' fater Supply We1i aridLcacngacluY E ,a11Y w exist oa seta or wittunD feet of Ieaehu�g facitg} Edge of wettand and Leaching Fap'l;ty(If aay�retlands exist Feet within 3tit}feet of leachi�f � ) � r FurW hed.by:` � y r v ® a� - Q3 ��I/- "Y --3 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE HINTER STREET. BOSTON. MA 02108 617-292-5500 WILLl.4>`f F.WELD �— V TRUDY CORE Govemor Secretan ARGEO PAUL CELLUCCI VID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I - Go�mmissioner PART A _ CERTIFICATION .Say f��`'/r ���f�Gr A p Property Address: / Address of Owner: RECEI� Date of Inspection: f!/ 17, /917 (If different) Name of Inspector: !�(l�/t¢� L' 4Q i4l JUL 2 8 1997 I am a DEP approved system inspector pursuant to Section M.340 of Title 5 (310 CMR 15.0 TOWN OFBARNSTAst� i Company Name: S£ �'k� Mailing Address: .O• �� ��'-7!� S HEAQHDEPT. � Telephone Number: D • b / � y CERTIFICATION STATEMENT E I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 4_ Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails inspector's Signature: 19e &�lDate: �A;1_ The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:11www.magnet.state.ma.us/dep ej Printed on Recycled Paper a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: V4 BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: 1 broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The s stem!re uired pumping more than four times a year due to broken or obstructed pipe(s). The system will ass _ , Y � ,q P P g Y P Pe Y P insPection uf,(with approval of the Board of Health): PP -' I broken pipe(s) are replaced '�*,- IWI obstruction is removed �oy Cl FUR THERi_ EV�A�L�U�ATION IS REQUIRED BY THE BOARD OF HEALTH: W`11 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 13) OTHER (revised 04/25/97) Page 2 of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: NYou must indicate "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. (Ir E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ No �/ _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or /' as part of this inspection. v _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ P g _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 is SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: = p.d./bedroorn for S.A.S. Number of bedrooms: Number of current residents: Z Garbage grinder (yes or no):L/D Laundry connected to system (yes or no): s Seasonal use (yes or no):A—/0 Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no)XV Last date of occu pan cy./4 `i7�j A,#COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: �� ��£f� i&za,/ ,S ti sii.y System pumped as part of inspection: (yes or no)o! V If yes, volume pumped: gallons �3 ��iyl E Reason for pumping: /r"10 w�t TYPE QFIYSTEM Y 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: U�L Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade:� � Material of construction: l�oncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Y-A S� f/— Sludge depth: � y Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: IQ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 0 How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to o����et Jj�p,vert, structural integrity, evidence of leakage, etc.) �4 SIAOW 15 f/�itfT/'A4 /fS ZZA Je GREASE TRAP: (locate on site plan) 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) W (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX. V (locate on site plan) Depth of liquid level above outlet invert: Comments. (note if level anq distribution`s equal evidence of solids car ,oyevidence of leakage into or out of box, etc.) CY 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 of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: o Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) e_ PRIVY: _ /T (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.) (revised 04/2S/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) f j �0-V 1 % J r� ANC 1 � JC .�, .• f (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwate;MFeet Please indicate all the methods used to determine High Groundwater Elevation: v/Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) V-/Determine it from local conditions . Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 l COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM PROFILE Flaherty Environmental Services TOP OF FOUNDATION BROUGHT TO WITHIN 6"OF FINAL GRADE J EL. 60.0' EL. 58.0' Snot to scale) INSP. PORT W I 3" OF GRADE CLEAN SAND P.O. BOX 81 2" of 8"to DOUBLE WASHED EL. 58.0' Yarmouth Port, MA 02675 4" CAST IRON or EQUIVALENT PEASTON5-OR GEOTEXTILE 774.994.1166 MIN. PITCH 1/4" PER FOOT FILTER FABRIC 4"SCHEDULE 40 PVC PIPE 4" SCHEDULE 40 PVC PIPE VENT IF REQUIRED • FLOW LINE (first 210 be leveD' ' 0' 1.5% 5. 10� ' 55.01 L.EXIST. EL.EXIST —�► 00000000000° ° 0 0 '®� �} o°o°o°00 EL.55.5' o 0 0 0 0 Y.• EL.55.03' i o000 0 0°c°c0000 � ®� °o°o°o°cc ' 0000c2.0 EL.55.2' o o°o°o°o°o°o°o �Rp O®��� ® o 0 o O EL.55.0' 0 0 0 0 0 0 0 0 °o°o°o°oc GAS BAFFLE °o°o°o°o°o o°o°o° . �00000000C ..-a• o00000000 000000 °°°o°o°o° EL.53.0' '•, • •• 6"CRUSHED STONE ORHzoD BOX) SOIL ABSORPTION SYSTEM •S' •' �''•''•'' MECHANICALLY COMPACTED t (2) 500 GALLON H-20 CHAMBERS '•••' • 1000 GALLON SEPTIC TANK MECHANICALLY • (DATUM: ASSUMED) (EXISTING) 3" to 11" DOUBLE WASHED STONE WITH 4'STONE AROUND IN A 12.83'X 25'X 2' CONFIGURATION BOTTOM OF TEST HOLE EL. 47.5' EL. 47.5' USGS ADJUSTMENT: N/A LOCATIONMAP GROUNDWATER ELEV: N/A As Built N TH F 504 Flint Street Lakeside Dr- LOCUS Marstons Mills, MA 7 ' O 1 C. amblin Rd. /nt 3 TO B NTS 1 2 3 4 DA ti A 31'4" 36'10" # 504 �R LA E R. O B 22'8" 18'3" 1 29'4" 326" C FLINT STREET /�• A Q C 26' 29'8" / S4 -TT DATE.'7/1.WO18 REVISED. o- 4 AS BUILT PLAN FOR B & B EXCAVATION, tNC./ ZACHARY MACDONALD 504 FLINT STREET BARNSTABLE (MARSTONS MILLS), MA NOT TO SCALE i REP PS 138 PG 25 PAGE 1 OF 1 f