The URL can be used to link to this page

Home My WebLink About0558 ROUTE 149 - Health 558 Route l 49 Marstons Mills "P {, A = 100 006003 _ TOWN OF BARNSTABLE LOCATION EWAGE # 97-176 ' VILLAGE M �1 I• ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO :1'1�e �� SEPTIC TANK CAPACITY ,/510 6-14 1 LEACHING FACILITY: (type) k) (- (size) J` -e:? 'Y Z' i NO.OF BEDROOMS BUILDER OR OWNER k PERMITDATE: !f- ?7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist _ within 300 feet of leaching facility) Feet Furnished by rr - r� t - Low, - 14c Commonwealth of Massachusetts _ W Title 5 Official Inspection Form p . Subsurface Sewage Disposal System Form - Not for VoluntaryiAssessrniN,v fA: 8L E ,n' c 558 Route 149 V�( Property Address e^ +J st ► Jack Goodrich 166 —66(y-W3 Owner Owner's Name information is Marstons Mills Ma. 02648-•------:,- 6& 36 898 required for ,.. every page. City/Town State Zip Code '10af k6nnspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name till I Qb P.O.Box 763 'Company Address Centerville Ma. 02632 'ems City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the nformation reported below is true, accurate and complete as of the time of the inspection. The inspection as performed based on my training and experience in the proper function and maintenance of on site o sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of itle 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes '❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/06/2008 Inspe or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 558 Route 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. . 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 558 Route 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ - Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ . The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 558 Route 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection B.. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 558 Route 149.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is"a cesspool serving a facility with a design flow of 2000gpd- 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. 558 Route 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection II C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 558 Route 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:43,000 g ( y g (gpd)): 2007:43 000 Sump pump? ❑ Yes ® No f Last date of occupancy: 6/06/2008Date 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: Last date of occupancy/use: Date Other(describe): 558 Route 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 558 Route 149 03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 558 Route 149 M Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. 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: 1500 gallon 211 Sludge depth: Distance from top of sludge to bottom of.outlet tee or baffle 30„ Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7-1 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured 558 Route 149-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to-outlet invert,evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene. ❑ other(explain): 558 Route 149.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carrrover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 558 Route 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2-58 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No evidence of hydraulic failure.No ponding or damp soil. 558 Route 149•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 558 Route 149 Property Address , Jack Goodrich Owner Owner's Name information is Marstons Mills Ma. 02648 6/06/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil,_signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan):' Materials of construction: Dimensions Depth of solids Comments (note condition of soil,'signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 558 Route 149-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Map• Page 1 of 2 Town of Barnstable Geographic Information System ` Parcel Viewer custom Map Abutters Map Size ® Zoom Out J 19 sty IN 1In 'V i R T Cr.Y•h•,f, . I\ / / � O / x. / / Y V. / r _ / \ / x 0 \ / 0 20 Feet ." 5R ...a......✓YY�>e 5 Set Scale 1" = 20 I Aerial Photos (`nnvrinhf 9MF_9MA T--of Ror—fohln AAA All rinhf.roenn.• http;//www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=100006003&m... 6/7/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 558 Route 149 Property Address Jack Goodrich Owner Owner's Name information is required for Marstons Mills Ma. 02648 6/06/2008 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: Bottom of trenches 50' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of ground water elevetions. 558 Route 149-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 of1He Town of Barnstable r� " regulatory Services BAMSTABLE, : Thomas F. Geiler, Director MA33. 9g, 2639. ,�� Public Health Division AlF p�,I A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable -Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:ISEPTIC\Disclaimer Private Septic Inspectians.DOC ' �'> _T ► 1 4-s COMMONWEALTH OF MASSACHUSE'-I'TS APR 15 2003 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI STOWN of STABLE HVETMYT. DEPARTMENT OF ENVIRONMENTAL PROTECT m � d f TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR V3Lfl NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ed, Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 V� Owner's Name: PHIL BURNS Owner's Address: 558 RT. 149 MARSTONS MILLS 02648 Date of Inspection: 3/20/03 (J3 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 MAP PARCEL. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and tha tQ�infonriatil7rr VIC U'b�h1•v 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 DE1'approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditional asses _ Needs Fu Evaluation by the Local Approving Autharity Fails Inspector's Signature: Date: 3/20/03 The system inspector shall submit copy of this inspection report to the Approvh,,;Authority(Board of Health or DEP)within 30 days of completing this inspec on. If the system is a shared system or has a deign 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. Tile original should be �. sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 TncnPrtinn Fnrm ril v,)nno i Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 Owner: PHIL BURNS Date of Inspection: 3/20/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If not determined please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 Owner: PHIL BURNS Date of Inspection: 3/20/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 Owner: PHIL BURNS Date of Inspection: 3/20/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN THE LAST YR INFO FROM OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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 " Y Y P g es"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. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 Owner: PHIL BURNS Date of Inspection: 3/20/03 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ 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(31(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 Owner: PHIL BURNS Date of Inspection: 3/20/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):aisr � Sump pump(yes or no):NO ��— �9CD�(jC�o Last date of occupancy: n/a C � ' _ OCU COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no):NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YR INFO FROM OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1997 INFO FROM ASBUILT Were sewage odors detected when arriving at the site(yes or no):NO 6 f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 Owner: PHIL BURNS Date of Inspection: 3/20/03 BUILDING SEWER(locate on site plan) Depth below grade: 20" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 14" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions:H 10' 6" H 5' 7" W 5' 8"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" r -E Distance from bottom of scum to bottom of outlet tee or baffle;, _1 r, How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THEY SYSTEM'S LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 558 RT. 149 MARSTONS MILLS 02648 LI12 Owner: PHIL BURNS Date of Inspection: 3/20/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND AND SYSTEM SHOWS NO SIGNS OF FAILURE. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 Owner: PHIL BURNS Date of Inspection: 3/20/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a 1 leaching trenches, number, length: 58 n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments note condition of soil signs of hydraulic failure level of ponding,dam soil condition of vegetation,etc.): ( g Y P g, p � g ) THE LEACH FIELD IS FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY.BOTTOM AT 5' CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 9 Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cont'.nued) Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 Owner: PHIL BURNS Date of Inspection: 3/20/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. e. ,5a 6 �(L I 5� in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 558 RT. 149 MARSTONS MILLS 02648 L112 Owner: PHIL BURNS Date of Inspection: 3/20/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY HAND AUGER- 12+FT. tt No. 7 7l Fee P 1 Q B % THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for �Migaal *pgtem Construction Permit Application for a Permit to Construct(VRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �,�'�\3, ap..c ,�� Owner's Name Address and Tel.No. Assessor'sMap/Parcel "�i� Cz�c\�a.h p�e�� 5 is �:E�`�► � InstalleissNarme Address,and Tel.No. ti �}� '7� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 73 Lot Size 3 AV,Ssq.ft. Garbage Grinder(ice) Other Type of Building No.of Persons Showers(-, ) Cafeteria( ) Other Fixtures Design Flow 0 gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date !tJl-Dead_ Title Size of Septic Tank 0 fas t;, Type of S.A.S. '�c�.e,, �•a e Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: W N 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 Certifi- cate of Compliance has been issu this Bo of He ^ - Signed (% +- V1✓ �9s"-�- Date Application Approved by Date T Application Disapproved for th ollo ing reasons Permit No 7 " 1 7G Date Issued kAp No. ; 76 Fee lee t Q o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for 3Digpogal *p5tem Con5tructiou Permit Application'for a Permit to Construct(%/Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �� Fyn Owner's Name,Address and Tel.No. = -, Assessor's Map/Parcel 1�� 8, 1 l �� („a►(\'c a�. d��. S p�i•81�`� •VY \bc) 00k, w Oil S.. A. Install�is Name,Address,and Tel.No. , �o '//I,?-)) Designer's Name,Address and Tel.No. Y G c o-aj t C En O�• ."�o�.<. �.c�c�. tad• a 7 tf So -oo ' Type of Building: Dwelling No.of Bedrooms Lot Size 3 wjsq.ft. Garbage Grinder Other Type of Building C, e :: n r^�No.of Persons Showers(a, ) Cafeteria( ) , Other Fixtures Design Flow ,b �>3 t, gallons per day. Calculated daily flow 3�i gallons. Plan Date \k\_X Number of sheets Revision Date Title Size of Septic Tank_� ,a ca E,a�+ Type of S.A.S. /-Tcs.c�,Q.n,•,S } Description of Soil S p 1. Crc cave. Nature of Repairs or Alterations(Answer when applicable) %%J\% x Date last inspected: e..j ." 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 Certifi- ,cate of Compliance has`been issued_hy this Bo of Hea �G�( 7 Signed' Date 7 Application Approved by Date 9 7 Application Disapproved for th6170,fJwing reasons Permit No. ' - Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed (��)Repaired( ) Upgraded( ) Abandoned(" )bye at _ � has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 5~ '7 Inspector _- ——————————————————————————————————————— No. 77, //.+ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'Wi0pogar *p!gtem Conotruction Permit Permission is hereby granted to Construct( Repair( )Upgrade( )Abandon System located at �_n J / t1�- 1 q f A4 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date:__ t-! - I 6n --97 Approved by K r _y{�, TOWN OF BARNSTABLE PT d k g �Gb Do oa.3 LOCATION .S J i EWAGE # 7 76 VILLAGE M AJZ _3 �► .S L l ASSESSOR'S MAP & LOT D► 2 ` INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 'r11UC �� (size) ��...� Z�Y r NO.OF BEDROOMS BUILDER OR OWNER'ry�,\ PERMTTDATE: COMPLIANCE DATE: f-1.5- 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by „ `9°(7 '`JtVQ? OQ • Town of Barnstable l'# s Department of Health,Safety,and Environmental Services IMF Public Health Division Date 367 Main Street,Ilyannis MA 02601 BARNRUBM MAIR lF�MKt�`� Date Scheduled d— �7 Time Fee Pd. /QU Soil Suitability Assess»ient for Sewage Disposal Performed By: 1 r -� Witnessed By: Q e. !•t l. � �►t -- -J T LOCATION & GENERAL INFORMATION fl p I �j n. J^ c r� Owner's Name N 1K� i'�'K S Location Address `� 1►� /►1 6� 1 Address 1,41 DouEe eoAdd Mtltrg MA, Assessor's Map/Parcel: 100 / b Engineer's Name NEW CONSTRUCTION REPAIR Telephone# so$ a fo26 -0063 Land Use F10-0 Slopes(%) O 'To Z°lo Surface Stones Ncn►E O Jep- Distances from: Open Water Body Sec') R Possible Wet Area 00 R Drinking Water Well 0LAIJ R Drainage Way R Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) ,D as , oTM_,P7-t� ' m 1'o 1?. LOT 12 1.JO AMES 135.97' Parent material(geologic)P1ec64-&ziat_ CeL4A 0 Depth to Bedrock N OM E Depth to Groundwater: Standing Water in I lole: N or.3JE� Weeping from Pit Face t4ON E Estimated Seasonal Iligh Groundwater llI;TEIzMINATION FOR SEMMNAI HIG14 WATER TAII E Method Used: 14411 6.M.- OF 1le+LC- Lao Depth Observed standing in obs.hole: / in. Depth to soil mottles: Nen+E in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment R. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST` bAle 3 zc 9 ` Time Observation Hole# Time at 9" Depth of Perc 4 Time at 6" IZ• Start Pre-soak Time c@ �' Time(9"-6") Z�j yRllan End Pre-soak Rate Min./Inch L C Z P1 Pr Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public health Division Observation Hole Data To Be Completed on Back—� Copy: Applicant DEEP OBSERVATION HOLE LOG Hole# D'TN- ti Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° O - Z AP SarP3 LoAM to -A'ytz 3I4 Nam' E yfZ 5�8 E mass t vE, FKIACUE 10 ON >G[v.� S Tart E L, SAN u Nc��.1E S�rE c- vet: �4_ )4A GZ selNd -I 3 'CEP DEEP OBSERVATION HOLE LOG Hole# tirO-Z. Depth from I Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) `tot,licg (Structure,Stcnes,Boulderes. 0 rAPc,5(VE/ t-R)Af,4jir Z A 6,1NO tcn.11� lt7 Y 3A tyt)rAE ��NE WIA55tYE� F✓rtAxc t2-3rn 6,� rv► tvAM to y�5 ANp Q G SAND Z,5 (o Q NotAc- G2PVEL v 36! 8 C-4,AvLc*- G 84-14 z sraNb Z,S�► 6 3 �� sarto DEEP 013SERVATION HOLE LOG Hole# Dcpth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Bouldcres. Consistency,°o ravel DEEP OBSERVATION HOLE LOG Hol e # Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° 'ravel) I Flood.]insui-aucc Rate Plan: / Above 500 year flood boundary No— Yes Within 500 year boundary No v/Yes Within 100 year flood boundary No V Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? y E 5 If not, what is the depth of naturally occurring pervious material? Certification I certify that on T'v,IJ E 96' (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required trainir ,expertise an xperience described in 310 CMR 15.017. 4 Date i!tnature �` 97 _ ... �i TOWN OF BARNSTABLE C &M, - 00 6.0103 LOCATION �"! �6 EWAGE# VILLAGES t 2U I L(. ASSESSOR'S MAP& LOT - A-2-INSTALLER'S NAME&PHONE N0.C:,VIA WkIA SEPTIC TANK CAPAC1Ty LEACHING FACILM: (type) PJCP(-,) (size) J�� X ry i NO.OF BEDROOMS BUILDER OR OWNER Nt J i-E »,►1 PERMTTDATE: Y -f 4 COMPLIANCE DATE: 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i D ® i f i 1 it 140 i a ,