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Home My WebLink About0041 SADDLER LANE - Health 41 Saddler Dune iviarstons-NIIiis - - -- -- - - -- - - - -- -- - A= 151 - 058 C i II Commonwealth of Massachusetts qqqq Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 41 Saddler Lane 9 Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner owner's Name information is West Barnstable MA 02668 May 12 2008 required for Y 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 B0`0 Citylrown State Zip Code 508-888-2805 S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes El Conditionally Passes El Fails ❑ Needs Further Evaluation by the Local Approving Authority '\ C= �a � ► May 14, 2008 Inspedo s Signature Date hJ Ca The system inspector shall submit a copy of this inspection report to the App ing Aut4p (Board of Health or DEP)within 30 days of completing this inspection. If the system share"ystelwor, has a design flow of 10,000 gpd or greater, the inspector and the system owne'shall suit Me,'� report to the appropriate regional office of the DEP. The original should be sent o 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. f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna,TR Owner Owner's Name information is West Barnstable MA 02668 May 12 2008 required for , every page. Citylrown 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: 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 placement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the❑ for he following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old* r the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltr tion or exfiltrabon or tank failure is imminent. System will pass inspection if the existing to is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspecti if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan is less than 20 years old is available. ND Explain: ❑ Observation of sewage ackup or break out or high static water level in the distribution box due to broken or obstructe pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(wi approval of Board of Health): ❑ broken pi (s)are replaced ❑ obstru 'on is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner Owner's Name information is West Barnstable MA 02668 May 12 2008 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cunt.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping mor than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(wi approval of the Board of Health): ❑ broken pipe(s)are re aced ❑ obstruction is rem ved ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board Health in order to determine if the system is failing to protect public health, safety or the a ironment. 1. System will pass unless Board of Health determ' es in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a urface water ❑ Cesspool or privy is within 50 feet a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board f Health(and Public Water Supplier, if any) determines that the system is func oning in a manner that protects the public health, safety and environment: ❑ The system has a septic nk and soil absorption system (SAS)and the SAS is within 100 feet of a surface w er supply or tributary to a surface water supply. ❑ The system has a se is tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a eptic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner Owner's Name information is West Barnstable MA 02668 May 12 required for , 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less t n 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, pe ormed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of a onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure teria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or No to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %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. 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y< 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner Owner's Name information is Y 12 West Bamstable MA 02668 May 2008 required for � � 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. P P vY ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 et of a surface drinking water supply ❑ ❑ the system is within 0 feet of a tributary to a surface drinking water supply ❑ ❑ the system is to ed in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)o a mapped Zone 11 of a public water supply well If you have answered"yes"to any estion in Section E the system is considered a significant threat, or answered"yes"in Section D a ve the large system has failed. The owner or operator of any large system considered a significant reat under Section E or failed under Section D shall upgrade the system in accordance with 31 CMR 15.304. The system owner should contact the appropriate regional office of the Depa ent. I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Saddler Lane Property Address The 41 'Saddler Lane Realty Trust/Paul Madonna,TR Owner Owner's Name information is West Barnstable MA 02668 May 12 2008 required for Y every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption SAS System on the site has y ( ► been determined based on: 0 ❑ 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)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner owner's Name information is required for West Barnstable MA 02668 May 12, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330.04 GPD Number of current residents: 0 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 years usage(gpd)): 2006=222 GPD 2007=57 GPD Sump pump? ❑ Yes ® No Last date of occupancy: Spring 2007 Date Commerciallindustrial 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., et Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to a Title 5 system? ❑ Yes ❑ No Water meter readings, if availa e: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner Owner's Name requiredu mation for West Barnstable MA 02668 May 12,2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owners records, Pumped Aug 2003(New SAS) Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: System installed August 1, 2003. As-Built and engineered plans on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes 0 No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner Owner's Name information is West Barnstable MA 02668 May 12 2008 required for Y every page. City/Town State Zip Code Date of inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 33" feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: N//A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 25"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: 8 X 4.5 X 4.5 Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1/2' Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape measure and dip tube Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner Owner's Name information is West Barnstable MA 02668 May 12 2008 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level 2"below outlet invert. Property has been vacant. No sign of leakage. Risers bring covers within 6"of grade. 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 o tlet tee or baffle condition, structural integrity, a r liquid levels q s related ted to outlet invert, evidence of le age, etc.): ) Tight or Holding Tank(tank must be p i� ed at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ meta1 ❑fiberglass ❑ polyethylene ❑other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y` 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner Owner's Name information is West Barnstable MA 02668 May required for W Y 12 2008 ' every page. Cityrrown 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 /filoatwitches, 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 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.): One inlet,one outlet. No solids carryover. No sign of high water staining over outlet invert. Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts ID Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner owner's Name information is required for West Barnstable MA 02668 May 12, 2008 every page. Cityfrown 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: El leaching pits number: ® leaching chambers number: 2-500 gal eachw/stone Q! 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.): SAS located and inspected with camera. Chambers dry at time on inspection. Staining 3"up from base of chamber. Clean stone visible thru side wall. No sign of past hydraulic failure Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna TR Owner owner's Name information is required for West Barnstable MA 02668 May 12, 2008 every page. Cityrrown 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 groundwat� 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, gns of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna, TR Owner Owner's Name information is y West Barnstable MA 02668 May 12 2008 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. i �-;,a".S cam•.-v G.Ji�tY+-�'-' f sya, J \ 1 1 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •' 41 Saddler Lane Property Address The 41 Saddler Lane Realty Trust/Paul Madonna TR Owner Owner's Name information is West Barnstable MA 02668 May 12 required for , 2008 every page. Citylrown 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: '5t 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: June 13, 2003 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: ma.water.usgs.gov town.bamstable.ma.us You must describe how you established the high ground water elevation: Test hole to 10.5'found no ground water. (2003)Base of SAS at 5'. Property elv. 136.1.Accessed local ground water contour and topo mapping. No high ground water near property elv. Town of Barnstable P�0*1HE 1p�� o� Regulatory Services BAMST,BLE, Thomas F. Geiler, Director p,Eo39�A Public Health Division 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 Inspections.DOC TOWN OF BARNSTABLE L�&nON All 6751d A/e r i( SEWAGE # Vl'LLAGE `)10,*56045 IA L s ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /OOC Q CL L Lon S LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER I�9 nt ✓a n S PERMITDATE: COMPLIANCE DATE: 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 -Page loot 11 - --• - - _ ._ _. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cmmnued) Property Addr Sosld(4 Owner. Date oflnspecdon: ' SKETCH OF SEWAGE DISPOSAL SYSTEM. P—dea stanch ofthe sewage disposal sysmmmclutling'ties to at'kast two petmanant reference lanAasrks or benchmarks.Locate all welts within 100 fret.Locate where public water supply chom thebuildiug. . ea t r 37 ors S� I 8 _ i TOWN OF BARNSTABLE LOCATION � cS,V WC4�-,,-z SEWAGE # G ' •�� VJTLLAGE,; r A + / SESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �� NO.OF BEDROOMS, BUILDER OR OWNER /v A PERMITDATE: COMPLIANCE DATE: O--,Z—GS 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 t- n s . ' ��/ > �. �� `�� ,� �� \ �`Y �.., -a", ` �``� TOWN OF BARNSTABLE LOCATION SEWAGE# 03 —3.S75-- VILLAGE Ct� , :�.. �.�, ASSESSOR'S MAP&PARCEL O _ INSTALLERS NAME&PHONE NO. �a�;vim_ ®�,�, �1 7 �7 SEPTIC TANK CAPACITY J Orb G�c� LEACHING FACILITY: (type) (size) •a -9'c-O C.( N< NO.OF BEDROOMS \3dx 0,5 -K �? OWNER 7 6.,-G PERMIT DATE: �7 _3 COMPLIANCE DATE: 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 Tr Rom, --1;r s - S" /--2 o F O 3; 71 Li�� Yrt 63�4L( a Lk e TOWN OF BARNSTABLE SEWAGE # G LOCATION ��' iL� - VILLAG ASSESSOR'S MAPP & LOT - INSTALLER'S NAME&PHONE NO. ------ ' SEPTIC TANK CAPACITY - `—� ` ��,��, �9"�, �, (size) �""'�.S•- '� LEACHING FACILITY: (type.- NO.OF BEDROOMS_ BUILDER OR OWNER PERMIT DATE: `�"31 3 COMPLIANCE DATE: "-�63 Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility.(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by � r d Pit �V Fee,5'0 OV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for Mioogal bpgtem Conotruction Vermit Application for a Permit to Construct( )Repair(,X/)Upgrade( )Abandon( ) O Complete System ❑Individual Components y Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map arcel —0 5g Installer's Name,Ad4ress,and Tel.No. _ Designer's Name,Addres and Tel.No. Type of Building: Dwelling No.of Bedrooms �J Lot Size sq.ft. Garbage Grinder(n Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re airs or Alterations(Answer w en applicable) /n SI 4 le&) �//c- 6' -a C� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir mental Code an of to place the system in operation until a Certifi- cate of Compliance has been i ed by this Bo f alth. / Signed Date f.. Application Approved by Date Application Disapproved for the following reason Permit No. Date Issued .>>; Fee�o Ov / . . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS TippYication for Migpogal *p5tem Construction Permit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) L1 Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. yl.SWvle/' j, c�nst4zk /Rek/rt Assessor's Map/Parcel —0 � Installer's Name,Ad ress,and Tel.No. _ Designer's Name,Address and Tel.No. �(/M• � rZO�IH��'! �`! - Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder `p Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets I / Revision Date Title % Size of Septic Tank -Type of S.A.S. f Description of Soil J J" Natured Re airs or Alterations(Answer when applicable)Ins loll 4 je&z /k . 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~an not to place the system in operation until a Certifi- cate of Compliance has been i . ued by this Bo Ho�ealth. Signed �. i a Date J Application Approved by v b �/ J4'/Ti�� ` f Date '11 /7 Application Disapproved for the following reason v + Permit No. Date Issued ,-'IoyJ2 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 j.[lrn C Rewlm SOo Do�� e✓v/G @-- at y,/ /,A17 2 (./, yX�i"/�.S`�!J/,�F has b onstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 14 Installer Designer The issuance o th's e t sal} Vonot be construed as a guarantee that the s�ys�te'�Will funo-ti�on� s-desgnet Date t/� Inspector i 1 t � V I V /� ` No. � � -----------------------Feet/ � �O THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migaal *pztem Construction Permit Permission is hereby granted to Construct( )Repair X)Upgrade( )Abandon( ) System located at /. jo2jr17 st�gG/E 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:Constrdction must be completed within three years of the date of this pe -' t. � / Date:_ I �� Approved by J J � f -- F � C T ION SEWAGE PERMIT NO. ; VILLAGE I N S T A LLER'S NAME i ADDRESS w B U I L D E R OR OWN ER i 'DATE PERMIT ISSUED ColI(a / DAT E COMPLIANCE ISSUED ®U .w h ' S �i L `�' FEa................ �-� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �- {: .1 :............OF........ STAO-i—E........................... Appliration for.Uiiipnattl Works Tonstruriion Permit , Application is hereby made.for a Permit to Construct' or Repair ( ) an Individual Sewage Disposal System art: 11. �• t , ......... LtJ. .. ---.'��.. ----• . tt thU -------------• -- 1+ .... .... ^ CLoc ion:Address or Lot No. - ............... .... ` - /.�.. Own r.-� Addrls�/ •4 G a ............... . .(� �1. Al ........................!. - ....... - ..-•-fir__--. .......................... Installer Address /� Type of Building . Size Lot..... Q T.....Sq..feet ; U �..� Dwelling—No. of Bedrooms...............��___........:...............Expansion Attic ( ) Gar age Grinder ( ) Other—Type T e of Building p� yp g............................. No. of persons............................ Showers. ( ) — Cafeteria ( ) a' Other fixtures W Design Flow.........1.A. ?........................gallons per jeraaw i r`�ay. Total d rl flow............:5_ .............0logs. WSeptic Tank=Liquid capacity.JOW..gallons Length.- -(C}_.... Width:5. .....Diameter................ Depth ....(�..... x Disposal Trench—No-------------------- Width.................... Total Length.........__... Total leaching area................:...sq. ft. Seepage Pit No........A........... Diameter........I&.... Depth below inlet...... Total leaching area-.."2 .,Zsq. ft. Z Other Distribution box � Dosing tank ) /f ''' Percolation Test Results Performed by...__ ". .L _.ri.,�i,........ Date......CP.//.. .. �_. if 4 r Test Pit No. 1._.....2-..minutes per inch Depth of Test Pit.. ......:_. Depth to ground water...__ . .. 0-4 Or. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... O u. ..........�.................. -----•-------� ,.......... c� Description of Soil...... ----(. A... 1 1 -� .�....... �. ................ - U ------------- ----------- ------------------- ..._..--•---•--.......... ---- . w ............................................................,-------------------------......---......��:t.L.` - =.................................... Nature of Repairs or Alterations=Answer when applicable.....................................................................................:......... ...............................-.-..........---.................... •..................... ........ ... _..........-------------------------•------------------•---------------..........................-- Agreement: The undersi ed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with, theprovisions of AI'PLEE 5 of the State Sanitary Code The u ersigned further agrees not to place the system in operation until a Certificate of Compliance has been • s d of health. Signed.—. ..................................... l ,-D Application Approved By.. ..... ........ .----•-.......---•--...--------------.. Date Application Disapproved for the following reasons:.............:...•-•-....--•--•--•---------..........................................•••--......._.............. .............................................................•-------.:.........--•---......--•-----...............--•--•------...........:................................-•••-•----••............------ Date PermitNo........� .:- .......................... Issued.......-----•--...-----••..................:............ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j . .{V..............OF........ ��I �/� � ? ��-�.'t,"� - Appliration for Disposal World Towitrurtion f rruti# Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: ................UU"O_!... M --------•- .......... ----•-----•---------------...... . 1 `Loc iiojn� Ad/drreps�s`(\� { } or Lot No. �L �! ♦�/ ry ............... .,JC�t' /T;1;:_ ...s.1�.1.��`.:?.?.!,•:P._.....•.............._._.... .. .`:.�F.tI:......! c....... .P..._ /:". $f..„ .0:....... .. a ..............: d t n1� ....OWS°+° G� �(� t�_� . � &.. jeS _...................................... f Installer Address Type of Building Size Lot...1��. .... der ( ) Other—T e of Building ............ No. of persons............................ Showers a YP g..........:...... P ( ) — Cafeteria ( ) Otherfixtures --- ......................... - .► .....--------••--•-•-•_.•--•- ...._................................... Design Flow.........►-._t.C>........................gallons per per_ion,per`day. Total d iil flow..........._._ :.,/_D...............gallogs. Septic Tank—Liquid*capacity.l .gallons Length._).O? ... Width_.T?;F.. Diameter................ Depth__ ...I.O..... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.........t........... Diameter........ ..... Depth below inlet...... �......Total leaching area.. .tlsq. ft. z Other Distribution box (° ) Dosing tank ( ) Percolation Test Results Performed by...... A� --:��7 V-.� 12 �% � Date.....�;g X �^��_r.. Test Pit No. 1__4- .minutes per inch Depth of Test Pit..._4 . ------ Depth to ground water..... D.�� .. (s. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ............................................................................--•-----................---•••6....•-•-•.._............. Description of Soil......:. #,.Ea N.NA........_ �._.''��a11f t1.....-•----I 7.-(`7 -�...1_�P��•�.�1[�� ..----•----•........ V --••-•. ...-•------•----•-------•--•..................•-----•------------------------------------------•••--A.L.,71C. .----=-------•----......-----------.....--•-------:......•---........_----•---- UNature of Repairs or Alterations—Answer when applicable....................................... ..................................:................... ...: ......... ...............•--------•-----.............. .....,.............•-------.....----....•-•....:-•-----•-----•----------•----------.....---••-.......... Agreement �,� agre s to install the aforedescnbed Individual Sewage Disposal System in accordance with The. undersi e1 the provisions of TITLZ 5 of the State SanitaZbeenl d The u ersigned further agrees not to place the system in operation until a Certificate of Compliance hasy t d of health. �f '`.Application Approved BY _••-•...........-•••-•-- Date Application Disapproved for the following reasons------------------------------------------------------------- ................................................... ..................................••----......--••-•......--••-•--- -•--............•-•••--•-------..................................................... ............---••----•--------•--............ Date Permit No........�:-...a ' I ............ Issued•....................................................... ,___,-, - ... ...» _.»...mow.... ��........_« .................r.._.......F.K.,..,_.........._.. THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH 17 ..........................................OF... �I .L .......................... Trrtifirair of Gautphattrr THLF KTO C7.URTIFY, T, t the Individual Sewage Disposal System constructed or Repaired ( ) •� Installer ._ has been installed in accordance with. the provisions of TIT LP, 5 of The S ate Sanitary Code as d scribed in the application for Disposal Works Construction Permit No....... 5-5� - .�-�-... dated---...-...��./..r5.f .................. THE ISSUANCE OF THIStCERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... .. f.. ............................ Inspector:------•----------�-- ------..-..---.-.- • , , ........................._.....,...y_ THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALT NO RjI ..........................................OF ....................... •••-• Fes...:_.,` _?. ..... aisposa orkD Toptrurt n rrrmit Permission is hereby granted......... .1�--..�._,�.'.... /��.�__. ___,. to Construct (` 'or Repaii ( _,,an Individua SO4age Dispo System ---- atNo............. . 7 _ f`-.........---• / �1 ..... Street as shown on the,apphcation for Disposal '.orlalConstructton Permit No:................L_1 Dated....__._..-.. ;f._.........._............ , Board of health DATE......b $� 5 ............................................. _/ r COMMON%MA q Ot��SSACLI SE S EXECUTIVE OFFICE OF ENVIRONTMEN-I AL AF'F AIRS DEPARTMENT OF ENVIRONIMENTAIL PFtOTEC"TION` 9 1/ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address- Qr _ s Owner's Name: Owner's Address: Ode.- CD Date of Inspection: IrL/�_ — C VX Name of Inspector:( leas print Company Name: c= -77 Malting Address: Uxop'li-ttl S Telephone Number: :D rn CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the local Approving Authority c Fails Inspector's Signature: r. 92� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: � 5 Date of Inspection: p — 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 1�.3-0-3 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 psed to be replaced or repaired_The system,upon completion of the replacement or repair,as approved e Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the folI ' g statements.If"not determined"please explain. The septic tank is metal and over 20 yes old*or septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration faihire is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank approved by the Board of Health. *A metal septic tank will pass inspection if it is Iiy sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old' vailable. ND explain: Observation of sewage backup o out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, ed or uneven distnNition box.System will pass inspection if(with approval of Board of Health): broken pipe(s)axe zeplaced obstruction is removed distribution box is leveled or replaced ND explain: The system re ' ed pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if( approval of the Board of Health): broken pipe(s)are replaced obstruction.is removed ND explain: 2 Lase 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: er- Owner: � Date of Inspection: d _ C- Further evaluation is Required by the Board of Health: Conditions exist which req uire further evaluation b is failing to protect public health,safery or y th e Board of Health in order to d rmine if the system the environment. 1. System will pass unless Board of Health determines in accordance wi 10 CMR 15.303(i)(b)that the system is not functioning in a manner which will protect public hea 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 vegetate etland or a salt marsh 2. System will fail unless the Board of Health(an ublic Water Supplier,if any)determines that the system is functioning in a manner that protects t public health,safety and environment: _ The system has aseptic tank and soil ab rption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surfs water supply. _ The system has a septic tank and S and the SAS is within a Zone I of a public water supply. — The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ethod used to determine distance "This system passes if well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile or is compounds indicates that the well is free from pollution from that facility and the presence of ammo a nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are Qered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM NOTFOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DJRPO&AL SySTEM INSPECTION FORM PARS'.A CERTIFICATION(continued Property Address: C Owner. Date of Inspection: D System Failure Criteria applicable to all systems: You mast 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'h day flow Required in more pumping 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. 0� 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.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic_compummds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is egwd.to:or less than Sppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.i have determined that one or more of the above failure criteria exist as described in 310 CUR 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 se a facility with a design flow of 10,000 gpd to 15,000 1'd• r You must indicate either"yes"or"no"to the following: (The following criteria apply to large syst in addition to the criteria above) yes no — — the system is within 4 feet of a surface drinking water supply — _ the system is w" ' 200 feet of a tributary to a surface drinking water supply — ' the syste s located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II a public water supply well If you have ered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Sec on 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 CUR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ARY ASSESSM ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ION FOR M PART B CHECKLIST Property Address: (Owner. a Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the folio ' Yes No _ Pumping information was provided by the owner,occupant,or Board of Health A- 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? 4 — 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 o e baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth r tscum? a _ 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: Yet no 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 CUR 15.302(3)(b)) l f page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: L., Owner: - `�` Date of Inspection: $ OS `p RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): t6r3 Number of bedrooms(actual):_ —3 DESIGN flow based on 310 CMR 15.203(for example: I 10 gpd x#of bedrooms): 330 Number of current residents: I Does residence have a garbage grinder(yes or no): /W ^� [if es separate inspection required]Is laun 'on a separate sewage system(Yes or no). = CD Laundry system inspected(yes or no): Seasonal use:(yes or no): *�V Water meter readings,if available(last 2 years usage(gpd)): tr � Sump pump(yes or no): /Nb Last date of occupancy: COMMERCIALIINDUSTRIAL r- Type of establishment: r�_ M Design flow(based on 310 CMR 15.2 apd Basis of design flow(seats/perso gft,etc.): Grease trap present(yes or no):_ Industrial waste holding resent(yes or no): Non-sanitary waste disc aed to the Title 5 system(yes or no):_ Water meter readings,i vailable:_ Last date of occupan lose: OTHER(descri ): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped deter mined? Reason for pumping: TYPE OF SYSTEM <Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank i Attach a copy of the DEP approval —Other(describe): Approximate age of all components date installed(if known)and source of information: 81 � 10� ��n �obt Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SU-BSUR#ACE 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: 1 Materials of construction:_cast iron Distance from private _ [/ 40 PVC_other(explain): water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:-(locate on site plan) Depth below grade. oZ 6 d Material of construction: concrete metal—fiberglass other(explain) - _polyethylene If tank is metal list age:_ Is age confirmed by a Certificate of Compliance certificate) p (yes or no —(attach a copy of Dimensions: Epp 61 Sludge depth: w Distance from top of sludge to bottom of outlet tee or baffle: c u Scum thickness:�N Distance 0 from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee orb ! e: !` 'r How were dimensions determined:— Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural irate as related to outlet invert,evidence of leakage, c.): ry>liquid levels °` GREASE TRAP:_(locate on site plan) Depth below grade: Material: construction:_concrete`metal fib m ass_polyethylene other {explain}; — _ Dimensions: Scum thickness: Distance from top of scum to top of et tee or baffle: Distance from bottom of scum t ttom of outlet tee or baffle: Date of last pumping: Comments(on pumping commendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet in rt,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: �g Bate of Inspe¢taon• D TIGHT or HOLDING TANK: (tank must be pumped at time of inspeciion)(locate on site plan) Depth below grade. Material of construction: concrete me fiberglass _polyethylene other(explain): Dimensions: Capacity: allons Design Flow: allons/day Alarm-present(yes or no Alarm level:Date of last pump" larm in working order(yes or no): Comments(con " on of alarm and float switches,etc.): DISTRIBUTION BOX:--I<—(if Present must be opened)(locate on site plan) Depth of liquid level above outlet invert:.etle, Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leaks a into or out of box,etc.): V q c PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no Alarms in working order(yes o}: Comments(note conditio pump chamber,condition of and pumps appurtenances,etc.): 8 page 9 g of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSUI&AC9 SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ A_leaching chambers,number leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level ofponding,damp soil,condition of vegetation, etc.): c ut� 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 in w(yes or no): Comments(note conditio f 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 conditio of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): -77 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE D SPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_AL SW Owner:_ 0 Date of Inspection SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system ineluding'ties to at least two benchmarks.Locate all wells within 100 feet.Locate where public watersupply Permanentm the builld ng. or l(. • F g t� i 3 Page I! of 11 OFFICIAL JNSpFCTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: p SITE EXAM Slope S(tcl lit' Surface water 0 Check cellar Y-of> Shallow welis yv0 Estimated depth to ground water 40 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:_ Observed site(abuvdng property/observation hole Checked with Local Board of Health-explain: within 150 feet of SAS) Checked with local excavators,installers-(attach documentation) _,6/Accessed USGS database-explain: You must describe flow You established the high ground water evation.: . i o veil vt e9 lI I N C0 Q MMON3E.�`I'':�Oz. ...,SACkiiU5E=1-1 EXECUTIVE OFFICE OF ENVIRONTI�IEN'TAL MFAIIt,S -r DEPARTMENT OF ENVIRONMENTAL PROT'ECTIOI�T` 5Y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �� Property Address: Q� r S Owner's Name: Owner's Address: AA /� c� Date of Inspection: �v Name of Inspector:( leas print Company Name: = -r. Mailing Address: 20►{ Lhg�Ci tp ✓� # Zi: Telephone Numbi E 73 a=3 c�^�1� r- CD M CERTIFICATION STATEMENT I certify that i have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection-The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority c Fails Inspector's Signature: ri Date- The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 { Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOL'CJN7ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: r ` Owne r: `�\Date of Inspection: OS 0 RESIDENTIAL FLOW CONDITIONS s-�[ ��i.+ � Number of bedrooms(design):gn)= Jt3 Number of bedrooms(actual): - 3 DESIGN flow based on 310 CMR 15.203(for example. 110 gpd x#of bedrooms): jh@9 �3a Number of current residents: l Does residence have a grinder o g r�inder(yes or no): /U') :a _• - Is laundry on a separate sewage system(yes or no):/�_D [if yes separate inspection required] f -" Laundry system inspected(yes or no): e-b j Seasonal use:(yes or no): - Water meter readings,if available(last 2 years usage(gpd)): =' Sum um p pump(yes or no): / ;.. Last date of occupancy: COMMERCIAUMUSTRIAL Type of establishment: ' Designflow/eR 310 CMR 15:2 apd Basis of desiseats/perso ft,etc.): Grease trap pes or no):Industrial wang resent(yes or ao): Non-sanitarysc wed to the Title 5 system(yes or no):Water meter ,i vailable:Last date of lose:OTHER(de GENERAL INFORMATION Pumping Records ' Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM QC Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of 0 components date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 t -� PLAN REFERENCE CONTOURS o Q��a� LL� PLAN BOOK 404 PAGE 100 EXISTING - - - - - - - 140 �r N o0 ASSESSOR'S MAP: 151fft i �mE FINAL GRADING TO BE PLACED �w o<w LOT: 58 $O THAT RAINWATER WILL NOT 0 >a _0 f POND OVER LEACHING GALLERY m Lows mNN O O SADDLER i `^ r o ' LANE MANE (_�� ` r WEST _� ROAD BARNSTABLE, MA za LOCUS MAP, 0p o �� ►-<o LOT 7 NOT a / TO SCALE w N I N w cwi, ! l42 l40 AREA - L5504 sf N V 138 z :/ R6 24 A x 125 F1 x 2 f i N J = W w LEACHNG GALLERY NV 3 -USE H-20 WTS w} V J =ao W LQ < z N 1101 "' VENT PPE s z LU _ C) LL 142. LEGEND Exis 0 W} o - tAOOO r L ON ~ -j ft W X O ` / SEPTIC TAAK Z0 J N n n Ln� / z — D-BOX 0-0 FX; W LL U(o _ '� / 3 B`T//�tG ` TEST PIT > wz D c'DR O u- 0)_ ` w To�� M E CM Prr UO zu zw 44 < p v) a9 f;�N ry c w w < rt, U) '- p-� to cn m � J / TREE (� 44.rase ATer5 TO DNPE7 C fp - v N AKt£S LE7J82 pBA�TE5 7YPE g{ e�OFAIA n`f� L.L O-OAK IhFpLLY PVPE ` L/ Uti 140 cy o DAVID "v+ CC GHANOW.R Ln � � N M w i Q� BENCH MARK Nl7 iPe' TOP OF FOUNDATION ELEVATION - 139.08 W v_ z USGS DATUM ASSUMED 3 w � w � o z -� u- . o LL<LL < Q SEWAGE DISPOSAL SYSTEM PLAN 0 oco LL v> U -TO SERVE EXISTING DWELLING o I I�, co w o w , 9 ROBERT & ANN MARIE FLOYD Q + - � S,9� 9�S/, 41 SADDLER LANE WEST BARNSTABLE. MA o �� o R ECO_TECH ENVIRONMENTAL, Q LL t2 €' �.� 43 TRIANGLE CIRCLE SANDWICH MA 0256 o P _J o ad PLAN 1 - 508 364-0894 LL SCALE: 1 in - 30 {t ETE 1456 I JULY 30.' 2003 A 1/2 THS PLAN IS TO BE CONSIDERED A DRAFT PLAN UNLESS IT SEARS THE STAMP AND SIGNATURE OF THE DESIGN ENGINEER ORIGINAL PLANS INTENDED FOR SUBMITTAL TO THE BOARD • OF HEALTH WILL BE SIGNED N BLUE AND STAMPED N RED. SOIL TEST LOG -DESIGN CALCULATIONS DATE OF TEST: JUNE 13. 2003 SOIL EVALUATOR: DAVID D. COUGHANOWR. RS WITNESS REQUIREMENT WAIVED - NO VARIANCES SOUGHT DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD NO GROUNDWATER TEST PIT I PARENT MATERIAL: EPROGLACIALDOUTWASH SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS ELEVATION - 136.1 ;- PERC AT 78 in : 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IS SOUND STRUCTURAL CONDITION, IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER vc Es) HOR¢ON TEXTURE (MUNSELL) MOTTLING DISTRIBUTION BOX: USE 3 OUTLET D-BOX. 0-21 FILL SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH 21-24 0 SANDY LOAM 10 YR 2/1 NONE FRIABLE A b o t - ( 24 x 12.5 ) - 300 s f 24-26 E SANDY LOAM 10 YR 4/1 NONE FRIABLE A s d w - ( 24 + 24 12.5 { 12.5 ) x 2 - 146 s f 26-30 A LOAMY SAND 10 YR 4/4 NONE FRIABLE Atot - 446 sf 30-46 B LOAMY SAND 10 YR 5/8 NONE FRIABLE Vt 0.74 x 446 - 330.04 GPD 46-126 C MEDIUM SAND 10 YR 6/3 NONE LOOSE-25% STONES USE A 24 ft x 12.5 ft x 2 ft GALLERY. V t - 330.04 GPD > 330 GPD REQUIRED GROUNDWATER ADJUSTMENT LEACHING GALLERY EXISTING BASED ONGROUNDWATER BARNSTABLE s�LL CONSTRUCTION DETAIL DEPARTMENT RECORDS DRYWELL UNIT -USE H-20 UNITS OBSERVED GW: 40.0 s'-6-x 4•-10'x 2'-9- STONE INDEX WELL: MIW-29 2 ft EFF. DEPTH ZONE: B 24.0 ft 7 READING: MAY 2003 LEVEL: 6.7 0 ADJUSTMENT: 1.0 ft ADJUSTED GW: 41.0tn 0CJ o ,A N T _ 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN o 2) ALL LINES TO/BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 3) ALL'•COMP..(5NENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS 8. 2 ft 8.5' 2.5' OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 240 f r NOT TO . 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES SCALE BEFORE EXCAVATING FOR SYSTEM. - 5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES SEWAGE DISPOSAL SYSTEM PLAN AND APPLIANCES, AND BIANNUAL PUMPING OF THE SEPTIC TANK 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT -TO SERVE EXISTING DWELLING PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. -10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. ROBERT & ANN MARIE FLOYD 11) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 41 SADDLER LANE WEST BARNSTABLE. MA STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED. STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING ECO-TECH ENVIRONMENTAL ;' 12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. 43 TRIANGLE CIRCLE SANDWICH MA 02563 y: ETE-1456 JULY 30. 2003 2/2