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HomeMy WebLinkAbout0059 SADDLER LANE - Health (2) It i 59 Saddler Lane { -- - — - Marstons Mills A= 151 - 060 ' I i No. cqol Fee ?5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:— Yes' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2[pphration for -Misposal Opstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( )' Abandon( ) ❑Complete System ❑Individual Components Location AZpYarcc4�elgyo . � Jr L.j� Owner's Name,Address,and Tel.No.(p(7— 757 &/� . I SqcPvt,1'� JAssessor's , / Installer's Name,Address,and Tel.No. Ste' 3(o;t dad 3 7 Designer's Name,Address,and Tel.No. J3,f,r/-IS Coni'd' iz aye 4 �f Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( )l Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title % /fir t�Lv 1i Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ; '<N;;p �6— I Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H alth. / S e Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued 6 4-7/ No. �-3 t✓� / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes _ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS RppliLation for Nspo8al *pstpm Construction permit f lApplication for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or�LotQNo. S 9 13gCj0j/ Owner's Name,Address,and Tel.No. 617` 7$�^ �¢0 Assessors ap arcel / I1ns^staller's Name,Address,and Tel.No. Sod- 3(,ol Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(.144 t Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title �� � a Size of Septic Tank Type of S.A.S. Description of Soil. Nature of Repairs or (Answer when applicable) /,(( S h Date last inspected: �-' Agreement: , The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system.in r accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of. Compliance has been issued by this Board of Health.. 'k Signed'" ,`1b .� `rj/ �' ' ' Date \ ( l Application A pproved by . N Date Application Disapproved by Date for the following reasons Permit No. —"" !c Date Issued --------------------------------- - - - - =r _____-____:_._ _ _e _- ----- -------------------- -__ _ .. __ _ -- - -' - 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 r(t is 43ccr nt.t-� Cc,,�) at yG�C `� f kvt s W4Sy Glgrin))g 01-e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No�� .J/ ,?vL dated Installer !—116 PJfd T q rs cc 1s)l` Designer #bedrooms %, Approved design ,ow {) d P � gP The issuance of his peerrmi shall not be construed as a guarantee that the system will fu fiction as designed. Date L ( l Inspector -- ------- - ----•-------- -------- - -- -------- -- ----------- -- ----- - �! - No. 1'"! � l !�4 - - . -------------Fee---- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construction permit Permission is hereby granted to Construct( ) Repair(Y) Upgrade( ) Abandon( j System located at q d ( Lei A-P , �.-p s) 06,qfI'1 rt � and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this peicit Date )�! !1 "% Approved bye � w �� y C5 .. � [S ° 3 " ,:�CEI. F O �� a No._..s��- b�� Fas....... THE COMMONWEALTH OF MASSACHusETTs BOARD OF HEALTH _ w.off........OF ... .....` INN Appliratiun for Disposal Works Tonstrurtiun Permit Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal System at: ................( .... .......... .._..................._. Locate Address or Lot No. ......... �I .. .s. yl........................ ................•-----..................... ..__..........._..........._............ Owner Address OGvtIV f1r�Jt>E . . ................................... ... ...... .............. M I taller Address �" Q7i Type of Building Size Lot.I.A.-Lug- Sq. feet U Dwelling—No. of Bedrooms.............7�....................Expansion Attic ( ) Garbage: Grinder ( ) '4 Other—Type T e of Building No. of persons............................ Showers — a YP g •........................... p ( ) Cafeteria ( ) p' Other fixtures d ........................•---_... d.� W Design Flow............t.t_(.....................gallons per.gam;}pefr dgy. Total daily Aow.............22 ............olons.( WSeptic Tank—Liquid capacit)L.1Q.gallons Length_--lt--. Width... .. .. Diameter............... Depth.. -:(D... x Disposal Trench—No. .................... Width::_.;.............. Total Length.................... Total leaching area....................sq. ft. ( 3 Seepage Pit No.................... Diameter....k{� ...... Depth below inlet....+.......... Total leaching area.Z0 ',.2-sq. ft. Z Other Distribution box (�) Dosing tank ( ) - aPercolation Test Result Performed by....2..r. 1 ,. .>�—u.-...........:... Date. f . .._P.� ..... 4Test Pit No. 1....4.......minutes per inch Depth of Test Pit....l.15�..... Depth to ground water.. .- ri, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 .......-... ....-•-•--••--..•t .......tf......................:......... .. O Description of Soil.. .......... U.#.... [ ..........�. -... 1.J�.---•-----(-�7i.------ C.1. �. � ��'Z W ..........`...............................•--........---------.....----•-•-----....-•-•-•-•---•---•------•-•-------.\&r/.. .). .. 1. .............•...... -•-•••••-•-----.....•-•--•.....................................................................................................................•--------......:_................._....--•••--•-•--...... U Nature of Repairs or Alterations—Answer when applicable............:.....................................................0.................0.......... .......................................................... ------------........-----.----..........................-.......................... Agreement: The under e� ees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'ITL,E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has s b e b of health. l Signed. .Y .. �. ........... ................ ll ................ � Date Application Approved By-----•...-.. ;'.... ...................................._ ........t o_.`.<._-g- Date Application Disapproved for the f lowing reasons:.......................................................................................................... ---.......-•--•____-•••-•---____................-----•--............-•-•-••------••................................... •-----•-•-•• Daw — PermitNo.......... .............................._._....._ issued......_............................_........-......... Dace i„r.....l.r-7"Yl�!!r';'�F'�`yYi+�'�Y-'41'� j4�t"�5fu,�n'-".#"�.yi^�n;R1=�.�.�'}�.dWF.+'�?`Pt'-�h�.�fi)+�r:��r. '.�''�i�iSV�"�'r1'n'('.•.,.,A�aJ•� °;xly�+�.`�L/1.�X}1'4$�f'`$Yr:.•w%';�,�71,11gt � �4v z No Fss........ �2 4 THE COMMONWEALTH OF MASSACHUSETTS } BOARD OF HEALTH i ... .. ... .... . .. Appliratuan.for Dts)XpDttlWorks Zonstrurtion Frrutit Application is hereby made for'a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: J ............ L� ;-.; • .;1...._?...:1...:....{� {.. ►. ,., ...................... t LA K.J ...................---...._..__ -- ............�. Location,--Address ....._......_... ......................................................or Lot No. . ..................... c .»......._.... t �.tAl Address f k....a ... ...... ....... .......................... ....... ...VrdV....fl�G f Installer Ad.. dress.... Type of Building Size Lot... . Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ' ) '4 Other—T e of Building No. of ersons____________________________ Showers — QI YP g ............................ P ( ) Cafeteria ( ) a' Other fixtures .. ...h___ z, W Design Flow............. .-_•-• ....gallons,per person>per day. Total daily flow................�:z-�_..____-___gallons.I WSeptic Tank—Liquid capacityl�.Wgallons Length..r�y-_a_t,.-_ Width_.. Diameter............... Depth... ..Lla.. xDisposal Trench—No...........:......... Width.................... Total Length.................... Total leaching�area.-___ __.__. sq. ft. 3 Seepage Pit N.o.........I........... Diameter...A�% -)-_.._._. Depth below inlet....4........... Total leaching area.���.Zsq. ft. Z Other Distribution box Dosing_ tank ( ) ts a Percolation Test Pit No. IS�:� __....minute peter nch Depth of Test Pi .._.. Depth to ground water.. .1 ►� k Li. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil......f.J ..... _f.....r _L(�..?...M.........I.��{�...`-�t ) J--------! 7 t` -_- ......................................................... (:L,E A�f ;�,.... i ... .. _ W ............... ......... �..---..........----•-•-•--.....--•----......•--••................-•-------•••--=--...-••.....\n,,l-�r11./1�. :�.�:"1..�............... "r ...................:..............................................................................•------... ..... -........ U 'Mature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement : :.:.sue . ............................................•---........--•-••-----•--•---•-• ......... The undersrg�fed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has • s ed by+JW({e�\fib of health. Signed .- ••-�`- ---•� _�"'`/ .. __........ l�.� S` ... Application Approved B ...... PP PP Y..... . - --•..... . ....................................•----- .................... .. - te.. ........ Date Application Disapproved for the 4102ving reasons_____________________________________•-----_•----...-___.....____•________....._..._...._-_._ ._........___ .....................•--..._..........------••-----•--...----••---•-•-•--------•----••.._.._......------.... ... .._...-•---- --•-._..-•--•-•-----..._...-- - ...------..._ Date — PermitNo...................................--........... Issued.---........................_......._......._.._.._ Daft C) THE COMMONWEALTH OF MASSACHUSETTS z tV ' � CT6 1 BOARD OF HEALTH . �} , ! /U.....� OF'........V.d iUs"T1P� ..................................... farrtif irate of Tout plitturr THIS IS TO-CERTIFY, That"the Ind,' iidual Sewage Disposal System constructed ( �or Repaired ( ) at.................... �.!.....y ...._....�' Q ( t IR.---•t- "(.....Install �.... .has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the ` application for Disposal Works Construction Permit No......................................... dated.......................................... :_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.- DATE............... ......q o.g ••................... Inspector......-..................2_..\=-:}....... .-."....K?!".....:....... i THE COMMONWEALTH OF MASSACHUSETTS 1 , BOARD OF HEALTH U w ���s-rv� tr)�E s—V 6 OF......................................................... .............. No...�..... ........ FEE. � '`' ' 1 .Disposal Works Tonstrurtion Vrrutit � ,r�,q +1,�K�y Permission is hereby granted ......................•---.... . ... to Construct , ) or u, 'r ( 1 ) an Individual Sewage D si sal System at No....... 'O i ° Cyr ---•--------=• -._..._..--•-c�--•-••-•--......... ..............•--.---------- ---------•------•--...---•-•----••------•--••---------.....--------•--.............. Street as shown on the application for Disposal Works Construction Permit N -------------- Dated.......................................... 1 ................. ................................... Board of Health DATE.........� ..-� .�_ �.:................... FORM 1255 HOBBS & WARREN, INC...PUBLISHERS `i., °��► I Town of Barnstable Barnstable Inspectional Services AII�MinicaCity BARNS"CaSLL 1 t 9 MASS. 039. Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A McKea n,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 7732 May 9; 2019 KELLOYAN, GEORGE & MOUMDJIAN, HARRY TRS 59 SADDLER LANE WEST BARNSTABLE, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 59 Saddler Lane, Marstons Mills, MA was inspected on 04/26/2019 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box is rotted and needs to be replaced. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\59 Saddler Lane Marstons Mills.doc ��°FTNET�ti Town of Barnstable ♦ r r r 3 BARNSPABLE. + Regulatory Services Department rEa r,tir►�°' Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑-Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code'§360-20 h) OTkWR box Repair deadline: 0:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc May 03 2019 1327 HP Fax page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -c/ 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name •°• information is !,Q required for every West Barnstable MA 02668 4-26-19 r page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. ```j111 t 41 I I I I II I I Imngoutf rms A. Inspector Information :'� . filling out forms ��+, on the computer, 5�, J A M E S N use only the tab James D. Sears =a :m key to move your Name of Inspector ; cursor-do not use the return Capewide Enterprises ., c a key. Company Name G�a 153 Commercial Street °��/irrsl fIMSPE`���``� —IG 11 Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification certify that; I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CM 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5-1 -19 ep6peotor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note; This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5lnsp.doc•rev.V2612018 Title 5 Othdel Inspedon Form:Subsurface Sewage Disposal system•Page 1 of 18 May 03 2019 1327 HP Fax page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wmv-1 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name information is required for every West Barnstable MA 02668 4-26-19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary:Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist,Any failure criteria not evaluated are indicated below. Comments: Conn. Pass D Box. The system is a 1000 Gal. Tank D Box and four chambers. 2) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7126/2018 Title 5 Official Inspecton Forn:Subsurface Sewage Disposal System•Page 2 of 18 May 03 2019 1328 HP Fax page 22 t Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 n 9 Saddler Lane Property Address George Kelloyan Owner Owner's Name information West Barnstable MA. 02668 4-26-19 required for every per, City)Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): Need to replace D Box. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: 15insp.doc•rev.MW2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 May 03 2019 1328 HP Fax page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name information Is required for every West Barnstable MA 02668 4-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*. Method used to determine distance; This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other 4) System Failure Criteria Applicable to All Systems: You must Indicate"Yes" or"No"to each of the following for all inspections; Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc•rev.7126120 18 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 4 of 18 May 03 2019 1328 HP Fax page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Saddler Lane Property.Address George Kelloyan Owner Owner's Name information is required for every West Barnstable MA 02668 4-26-19 page. City/Tom State Zlp Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in mooed is less than 6" below invert or available volume is less than '/2 day flow )-64Q11*6 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped; ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of.custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system falls. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section 0.4. 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 I I of a public water supply well t6insp.0oe•rev.7/26/2016 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i May 03 2019 1328 HP Fax page 25 c Commonwealth of Massachusetts Title 5 Official Inspection Form kr�wj — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Saddler Lane Property Address George Kelloyan Owner Owners Name information Is required for every West Barnstable MA 02668 4-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cant.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any,large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no" for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ 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 NIA) ® ❑ 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)] Nns .doc•rev.712SQ018 p Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 6 of 18 May 03 2019 1329 HP Fax page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 59 Saddler Lane 'i Property Address George Kelloyan Owner Owner's Name information is required for every West Barnstable MA 02668 4-26-19 page. CityrTown State Zip Code Date of Inspection D. System Information 1. 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 Description: 1000 Gal. Tank D Box and four chambers, Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2017-299,000Gal g ( y g (gp )) 2018-157,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t8insp.doc•rev.7126)2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 May 03 2019 1329 HP Fax page 27 c \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y ry 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name Information is required for every West Barnstable MA 02668 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203); Gallons per day(9pd) Basis of design flow(seats/person s/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form!Suhsurface Sewage Disposal system-Page a of 18 May 03 2019 1329 HP Fax page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form / Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name equiretlon is r d for every West Barnstable MA 02668 4-26-19 require page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1998 Permit # 98 -435. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 4'-10" feet Material of construction: ❑cast iron ®40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): _Pipeing is 4" PVC SCH -40. I t5lnsp.do:•rev.7126/M18 Title 5 Official Inspection Form:subsurface Sewage Disposal system•Pege 9 of 18 May 03 2019 1329 HP Fax page 29 Commonwealth of Massachusetts :. Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name information is required for every West Barnstable MA 02666 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 6. Septic Tank(locate on site plan): Depth below grade: 4 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level.Tank and inlet cover at 4' below grade. Outlet cove at 3'. Two inlet tee's w/outlet baffle. No sign of leakage or over loading. t5insp.doc•rev.7/2612018 Tide 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 10 of 18 f May 03 2019 1329 HP Fax page 30 c °y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Saddler Lane Property Address George Kelloyan Owner Owners Narrle information Is required for every West Barnstable MA 02668 4-26-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): B. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 15insp.doc•rev.7/2512018 Tille 5 Official Inspection Form;Subsurface Sewage Disposal system•Page 11 of le May 03 2019 13:30 HP Fax page 31 Commonwealth of Massachusetts UR- w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not forVoluntary Assessments 59 Saddler Lane Property Address George Kelloyan Owner Owners Name information is required for every West Barnstable MA 02668 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): r 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 16"x21"-30"below grade w/one line out. Well's are gone on box. Need to replace D Box. tSinsp.doc rev.7/2 612 0 1 8 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 12 of 18 May 03 2019 13:30 HP Fax page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Saddler Lane Property Address George Kello an Owner Owner's Name information is required for every West Barnstable MA 02668 4-26.19 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: . ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc•rev.N26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 May 03 2019 13:30 HP Fax page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name information is West Barnstable MA 02668 4-26-19 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cunt.) Comments (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.): Leaching is four infiltrators. Chambers at 3'below grade.Camera out line. No sign of over loading or solid carry over. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): 15insp•doc-nw.712612018 Ti4e 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 May 03 2019 13:30 HP Fax page 34 Commonwealth of Massachusetts 5� Title Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name information is requlnea for every West Barnstable MA 02668 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): 15lnsp.doc•rev.7/26/2018 Title 5 Offidel Inspection Fo:Tn:Subsurface Sewage Disposal System•Pape 15 of 18 ( i May 03 2019 13:30 HP Fax page 35 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form • Not for Voluntary Assessments v,. 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name information is required for every West Barnstable MA 02668 4-26-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5insp.doc•rev,7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of f 8 May 03 2p19 13,30 HP Fax page 36 Apr 1719,03;18p Capewide Enterprises 508-477-0977 p18 TOWN OF gARNSTA.BLF V LOCA710N ��� SE AGE N -U3.f VIUAGfi 1a01r._, A s S`goft' MAPaLOT_/r -o(p0 WSTALLMISNAD1M PH(]JSNO. r"(11 SEMC TMX WAcrry LEACHING FACttrr7;(rype�_W'k.•r n��Fv r�nt�i �,x c a NO.OF BEDROOMS aw.oeR o ik e�-� PERMITDAM- 7-10-5 Sr-�CQMPUANCE DATE._ Sepwatioa Distance 8elweeo the; Maximum Adiasled Groundwacer Tab)a eo tleBolwmof Leaching Fadlity Fx ?tivatc WUN Supply Wall and I caching Facility (Lr nay Wells exial on aita or within 200 leer or leaching belly) Feet Forge of WeVand and Leaching FaciUly(V any wallersds cxisl wi&n 300 feel or inching raa4 ) Fumisbed by A � r�l•1,�1� I 3- a 3:57' 3 e � Can1� c(? ar„� n May 03 2919 13:30 HP Fax page 37 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name information is required for every West Barnstable MA 02668 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N0 10, Estimated depth t high ground water: 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Auger T.H. 10'no G.W.. Bottom of chambers at 3'-10" below grade. Bottom of chamber's at 6'-2" above T.H. Depth.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. lbinsp.00c•rev.7/2 612 0 1 8 Title 5 0ffldsl Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 May 03 2,Q19 13:31 HP Fax page 38 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Saddler Lane Property Address George Kelloyan Owner Owner's Name informationis requiredairedfor every West Barnstable MA 02668 4-26-19 for page. City/Town Slate Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form Inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certificabon: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For'8: Tight/Holding Tank-Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included rr Ro 3-109P me CRY to rya IV 0 Gw t5insp.doc•rev.7JM2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 18 low .fig. r _ • 1 ' Be Used For the Renair:Of Failed NOTICE: This Form Is To r Septic Systems Only. Y CERTIFICATION OF SKETCH AND APPLICATION FOR : f CERTI (WITHOUT_ : . DISPOSAL WORKS CONSTRUCTION PERMIT ' ENGINEERED PLANS lication for disposal Works , Y hereby certify that the app y_ o concerning the it signed by me dated g� construction perm . mats all of the property located at 5 5 , following criteria: Im.Is Thera aro no wetlands located within 100 feet of the ProPosed � , f are no private wells 1 SO s w feet of the"posed , septic"110111 There change in use immmed There is no hlcroase M flow a<tdlor c ge f There are no vsriattoes rt�lested or nWed. proposed leaching facility will be located within 230 tea of any wetlands,the bottom of the if the `�. kachMg facility will IIl:t be IoGated less than�foutteen(14)feet above the maximum adjusted ' potmdwater table elevation. - Please complete the following: La A)Top of Ground Elevation(awing to the Engineering Division 0.1.3.meP) 1 atceording to Health Division well map)._..���`O B)0 aronndwater Table Elevatton( 06 .� II DATE: ....ac..-�- S10NE0 t: LICENSED SE SYSTEM IMAME TOWN OF BARNSTABLE NIIMBBR of dw ayNw++.Abe If t1w Ile"OW Indellw POMM a eerllAt>a plot plan. (Ataeh a alcNah plan ProPe� this plan should be submitted). ' �.. 1b11ec sat i -for r TOWN OF BARNSTABLE LOCATION s &M 1 E tr SEWAGE # VILLAGE, �R,, l `atl e- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 00 t CA Ca ram. SEPTIC TANK CAPACITY _i Q0Q ,a I C LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER O OWNE PERMITDATE: 7 —/0-2 _COMPLIANCE DATE:_ 7 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 facili ) Feet Furnished by cx� .rq. A , i � r 30 - 3457' ,, p C 'y C r� S� DD - E i��� � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 every page. City/Town Date State Zip Code Date of of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out A. General Information forms on the computer,use 1. Inspector: y� only the tab key ok to move your DOUGLAS A. BROWN cursor-do not use the return Name of Inspector key. D.A. BROWN I "` Company Name z r_.a, tab P.O. BOX 145 r4; _ cv Company Address ' CENTERVILLE c' -f> City/Town M� '02632 -- _-i p Code �.? 508-420-4534 S 14297 Telephone Number License Number B. Certification I certify that I have personally p sewage inspected the g disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/30/07 Inspec Sig u Date The system nspector 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. Title V Inspection Fonn.doc•()8/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 7I30/07 every page. Cltyfrown 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. Commews: SYSTEM APPEARS TO MEET MINIMUM REQUIREMENTS AT THIS TIME, NO OBSERVATION PORTS ON LEACHING SYSTEM 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 Title V inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface D'sewage g Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTO,N Owner Owner's Name information is MARSTONS MILLS required for MA 02648 7/30/07 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 tim es 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. Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 7/30/07 every page. Cltylrown 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 ❑ ® 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. Title V Inspection Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 59 SADDLER LN Property Address NAUGHTON Owner Owner's Flame information is MARSTONS MILLS required for � MA 02648 7/30/07 every page. Cityfrown 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® 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. Title V Inspection Form.doc•08106 Title 5 Official insp ection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 7/30/07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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)] Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 every page. Cityfrown Date/07 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: 3 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 06/202-07/99 Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis,of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Title V Inspection Fonn.doc•OS/QB Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 7/30/07 every page. Cdyrrown State Zip Code Date of Inspection D. System Information (cunt.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? SITE GLASS ON TRUCK Reason for pumping: NEEDED PUMPING Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 7/15/1998 MID CAPE SEPTIC Were sewage odors detected when arriving at the site? ❑ Yes ® No Title V Inspection Form.doc-08tt)6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name requmation is MARSTONS MILLS required for MA 02648 7/30/07 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction liner feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 GALLON Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle 0 Scum thickness 0 PUMPED AS PART OF INSPECTION Distance from top of scum to top of outlet tee or baffle 00 Distance from bottom of scum to bottom of outlet tee or baffle 0 How were dimensions determined? Tide V Inspection Form.doc•08106 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7/30/07 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK NEEDED PUMPING BADLY,HEAVY SOLIDS IN TANK,PUMPED BY SCOTT FRANK 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): Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 7/30/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cunt.) 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 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.): D-BOX SHOWED SOME SIGNS OF CORROSION, AND SOME SOLID CARRY-OVER DUE TO LACK OF MAINTENANCE, BUT IT WAS FLOWING FREELY INTO S.A.S. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title V Inspection Form. p� doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 7/30/07 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: NO OBSERVATION PORT Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): COULD NOT OPEN CHAMBERS DUE TO NO OBSERVATION PORT,THERE FOR COULD NOT MEASURE THE LEVEL OF PONDING. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is MARSTONS MILLS required for MA 02648 7/30/07 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.): Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 f Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name infguired ormation or is MARSTONS MILLS re f MA 02648 7/30/07 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. A-; I 31 z 381 0 3 5G `G `/ T S7i 3 Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 SADDLER LN Property Address NAUGHTON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7/30/07 every page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record It checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Tide V Inspection Form.doc•08M Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 i Town of Barnstable F THE T°k Regulatory Services sARNSTABLE., Thomas F. Geiler,Director MAM 1619. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 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/copy of this report;this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s 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 Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. f r N k N o .4 � age �r q ,' i 104A � I rbAq F / ._ C €. . A WL. iN w G v,06 F , 90.00' LOT 9 800t SF / J LOT 43 = 14,718f SF �O PROPOSED NOTE: LANDSCAPING DETAIL, GR ADDITION LEVEL DECKS, GAZEBO, ETC. IN YARD ARE NOT SHOWN. A 11.3' O EXISTING o DWELLING / N N 8.9' 14.00' 12.2' r� ORIGINAL ZONING 1985 am RF CLUSTER DEVELOPMENT 00 UP TO 75% REDUCTION IN SETBACKS: FRONT: 30' TO 7.5' MIN. SIDE: 15' TO 7.5' MIN. REAR: 15' TO 7.5' MIN. 85.00' Saddler Lane DCE #07-256 BUILDING PLOT PLAN (SHOWING PROPOSED ADDITION) PREPARED EXCLUSIVELY FOR THE PURPOSE OF OBTAINING A BUILDING PERMIT, NOT FOR ANY OTHER USE LOCATION 59 SADDLER LANE (WEST) BARNSTABLE , MASS. PREPARED FOR: SCALE : 1" = 30' DATE : SEPTEMBER 19, 2007 GEORGE KELLOYAN REFERENCE MAP 151 PARCEL 60 �-cw oF,l�ss I HEREBY CERTIFY THAT THE STRUCTURE �o`'� ARNE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. o H. OJALA fn off 5 362-4541 ,� No,26348 fox 5w 08 382-9880 P , � QO � down cope engineering, inc. !q SS CI WL ENGINEERS LAND SURVEYORS DATE REG. LAND SURVEYOR 939 Main Street — YARMOUP-IPORr, MASS � 90.00' `SLOT 9 800f SF/� �7 s v OT 3 14,718 SF r st— -� s-f�ADP F�•v�P PROPOSED NOTE: LANDSCAPING DETAIL, GROUND i� ADDITION LEVEL DECKS, GAZEBO, ETC. IN REAR YARD ARE NOT SHOWN. 00 EXISTING b DWELLING / N N 0) 8.s' 14.00 12.23 reC'� r} Rgq3 S co 85.00' Saddler Lane DCE #07-256 BUILDING PLOT PLAN (SHOWING PROPOSED ADDITION) PREPARED EXCLUSIVELY FOR THE PURPOSE OF OBTAINING A BUILDING PERMIT, NOT FOR ANY OTHER USE LOCATION : 59 SADDLER LANE (WEST) BARNSTABLE , MASS. PREPARED FOR: SCALE : 1" = 30' DATE : SEPTEMBER 19, 2007 GEORGE KELLOYAN REFERENCE MAP 151 PARCEL 60 I HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. off 5W-362-4541 fox 606 362—SM down cape engineering, inc. CIVIL ENGINEERS LAND SURVEYORS 939 Moin Street — YARMOUTHPORT, MASS DATE REG. LAND SURVEYOR C. 1:1 r TOWN OF BAMSTABLE (r t� LOCATIONQ4 //rr C�SEWAGE # /0 ,,,,,, raf' —G(3S , VILLAGE e /'t�J ES ASSSOs^'R' MAP & LOT IS —6&0 INSTALLER'S NAME&PHONE NO. 1 f-A CG►. rie !kp+1c i SEPTIC TANK CAPACITY a 0, LEACHING FACILITY: (type) �"�" i' NO.OF BEDROOMS BUILDER OEQOWNE PERMIT DATE: - /0` COMPLIANCE DATE: '7 Separation Distance Between the: i 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 facili ) Feet Furnished by i i kocn 4 Lo C� �? CY?(0 U7c 11.1 o � t G 0 v i Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 John Grad D.F.P. Title V Septic Inspector P.U. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor x ARGEO PAUL CELLUCCI �► Lt.Governor SUBSURFACE SEWAGE DISPPOOSSALASYSTEM INSPECTION FORM �f• �, CERTIFICATION (/Z dFIke- +. MC,:P t 5 1 r" �U L C4 c1 r-A Property Address: 59 Saddler Ln.West Barnstable (I Address f Owner: Date of Inspection: 6115/98 �lT�g9 I`A� Name of Inspector: John Grad Scott Myers �I �FArTSeIF 8 I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: Q l 6 � 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: — Passes This Inspection Is based on criteria dented In Title V Conditionally Passes code 310CMR16303.My findings are ofhow the system is performing atthe time of the inspection.My Inspection does _ Needs ur er Evaluation By the Local Approving Authority notimptyanywarn tyorguaranteeofthelongevityofthe x Fal IS septic system and any of Its components useful life. Inspector's Signature: Date: 6no196 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: _I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of C07hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 59 Saddler Ln.West Barnstable P Y Owner: Scott Myers Date of Inspection:6115199 D]SYSTEM FAILS(continued) Yes No — 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 1/2 day flow. x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). — Numbers of times pumped X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. —x- Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No 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 II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)97) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 59 Saddler Ln.West Barnstable Owner: Scott Myers Date of Inspection:6/15198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H.' x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revised 0427)971 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 59 Saddler Ln.West Barnstable Owner: Scott Myers Date of Inspection:6115f98 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 9•p d./bedroom for S.A.S. Number of bedrooms: a Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye: Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): nta Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day 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: rda Last date of occupancy: nta OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection:(yes or no)No If yes,volume pumped:0 gallons Reason for pumping: wa TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components, date installed(if known)and source Information: 10 years old Sewage odors detected when arriving at the site: (yes or no) No (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Saddler Ln.West Barnstable Owner: Scott Myers Date of Inspection:6115198 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate_metal_FRP_Polyethyiene—other(explain) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le6"H67^W4.10'- Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle:B" Distance form bottom of scum to bottom of outlet tee or baffle: 16" How dimensions were determined: measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound and functloning properly.Recommending pumping every two years. GREASE TRAP:_ (locate on site plan). Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: rda Date of last pumping;,l_ Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: TV Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction linetown Diameter: 4" Qmments: (conditions of joints,venting, evidence of leakage, etc.) Irevlsed 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Saddler Ln.west Barnstable Owner: Scott Myers Date of Inspection:6115198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: eta Capacity: rda gallons Design flow: rda gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: liquid level vvithbottomofpipe Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) D$ox Is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ves Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 59 Saddler Ln.West Barnstable Owner: Scott Myers Date of Inspection:5115198 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits, number: one 1000yallon leach pit leaching chambers,number:nla leaching galleries,number: rea leaching trenches, number,length: nla leaching fields,number,dimensions:rda overflow cesspool, number:nla Alternate system: nla Name of Technology:_Wa Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pit la pastthe effective depth of leaching.The ass Is In hydraulic fallure.PItwea full. CESSPOOLS:_ (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: rda Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: nla Materials of construction: rda Indication of groundwater: We inflow(cesspool must be pumped as part of inspection) We Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda PRIVY:_ (locate on site plan) Materials of construction: rda Dimensions: da Depth of solids: nla Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nfa revised 0427)97 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 59 Saddleback Ln.West Barnstable Scott Myers 6115198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) ran- �ti�ti t A a AA �1, q6 Page 9 of 10 (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 59 Saddler Ln.West Barnstable Scott Myers 6115198 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts (revlsed042T197) page 10 a[ 10 r t a 1 Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 John Grad D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAMF.WELD S6 Governor $ Govemor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPPOOSSALASYSTEM INSPECTION FOR ' CERTIFICATION ,7 'Pee T. l0 6' M ` S1 Oleo rga1`9'98 Property Address: 59 Saddler Ln.West Barnstable ` ` ` Address of Owner: y NS Date of Inspection: 6/15/9s (If different) Name of Inspector: John Graci Scott Myers f I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: ' 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes This Inspection Is based on criteria defined In Title V Conditionall Passes code 310CMR16303.My findings are ofhow the system is performing at the time of the inspection.My inspection does — Needs Ar er Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthelongevityofthe x Fal IS septic system and any of Its components useful lire. Inspector's Signature: Date: 6130198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. i INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoTnpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04f27)97) One Winter Street is Boston,Massachusetts 0210E is FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 59 Saddler Ln.West Barnstable Owner: Scott Myers Date of Inspection:5115199 — Sew.acie backup or,breakout.or hiclh.static water level obser.ved.in.the distribution b.ox is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or priivy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: x I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No -X— Backup of sewage in facility or system component due to an 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 cesspool. x_ — SAS is in hydraulic failure. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 59 Saddler Ln.west Barnstable Owner: Scott Myers Date of Inspection:6115199 D]SYSTEM FAILS(continued) Yes No — 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 1/2 day flow. x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. —x Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No 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 II of a public water supply well) The owner or operator of any such system shall bringthe system and facility into full compliance with the groundwater treatment program Y tY P 9 P 9 requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)971 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 59 Saddler Ln.West Barnstable Owner: Scott Myers Date of Inspection:6115198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x — None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. —x— — The site was inspected for signs of breakout. x — All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected — — for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x — The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)) (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 59 Saddler Ln.West Barnstable Owner: Scott Myers Date of Inspection:6115199 FLOW CONDITIONS RESIDENTIAL: Design flow: = g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): nla Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day 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: nra Last date of occupancy: nra OTHER:(Describe) rJa Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rda System pumped as part of inspection: (yes or no)ldo If yes,volume pumped:0 gallons Reason for pumping: rila TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 10 years old Sewage odors detected when arriving at the site: (yes or no) No (revlsed 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 59 Saddler Ln.West Barnstable Owner: Scott Myers Date of Inspection:6115198 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: LeY"H67"W4911" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 16" How dimensions were determined: measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound and functioning properly.Recommending pumping every two years. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: n1a Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: rda Date of last pumping, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 2-6" Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line" Diameter: 4° Qmments:(conditions of joints,venting,evidence of leakage, etc.) (revised 04127197) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 59 Saddler Ln.West Barnstable Owner: Scott Myers Date of Inspection:6115f98 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: nra Capacity: nta gallons Design flow: nra gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: liquid level with bottom of pipe Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) D$ox Is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ve: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revleed OW7197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 59 Saddler Un.west Barnstable Owner: Scott Myers Date of Inspection:6115198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: 3ns1000gallon[each pit leaching chambers, number:rue leaching galleries, numoer: rda leaching trenches, number,length: Na leaching fields, number, dimensions:nla overflow cesspool,number:nla Alternate system: Na Name of Technology:_Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The leach pit Is past the effective depth of leaching.The sas Is In hydraullc failure.Liquid level In leach pit was above Invert plpe,into risers. CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert:rua Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: -Ja inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil., signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY:_ (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na 9 (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 59 Saddleback Ln.West Barnstable Scott Myers 5115198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) l A a q6 Pape ! of ao Inri.•a oem>s�) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 59 Saddler Ln.Wrest Barnstable Scott Myers 6115199 Depth of groundwater 12. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts S (revlsed0412T197) Fag* 10 at 10 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS :S DEPARTMENT OF ENVIRONMENTAL PROTECTION lug TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM F PART A RECEIVED CERTIFICATION Property Address: 59 Saddler Lane APR 2 9 ZOOZ West Barnstable TOWN OF BARNSTABLE Owner's Name: Jeff Lena HEALTH DEPT. Owner's Address: Date of Inspection: 4/4/2002 Name of Inspector: (please print) Kevin J. Sullivan !. Company Name: Ready Rooter Mailing Address: P.O.Box 371 PARCEL ' O Sandwich,MA 02563 Telephone Number: (508)888-6055 LOT 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 Authority Fails Inspector's Signature: f / Date: 1I-9-a2 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. • rurpcutii OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 59 Saddler Lane West Barnstable Owner: Jeff Lena Date of Inspection: 4/4/2002 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: V-'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 repl or repaired.The system,upon completion of the replacement or repair,as approved by the Board of th,will pass. Answer yes,no or not determined (Y,N,ND)in the for the following statements.If of determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether etal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is immine .System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Bo d of Health. *A metal septic tank will pass inspection if it is structurally sound,not 1 ng 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 s is water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven di 'bution box.System will pass inspection if(with approval of Board of Health): broken pi s)are replaced obstru on is removed di u *on box is leveled or replaced ND explain: The system required pump' g more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approv' of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: t- Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION(continued) Property Address: 59 Saddler Lane West Barnstable Owner: jeff Lena Date of Inspection: 4/4/2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health ' order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determin ' accordance with 310 CMR 15303(1)(b)that the system is not functioning in a manner which protect public health,safety and the environment: _Cesspool or privy is within 50 a surface water _Cesspool or privy is withi eet 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 withi 00 feet of a surface water supply or tributary to a surface water supply. T The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 f of a private water supply well. —The system has a septic tank and SAS and the SAS is less an 100 feet but 50 feet or more from a private water supply well". Method used to determine di ce "This system passes if the well water analysis,pe rmed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate ni gen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the an is must be attached to this form. 3. Other: 9 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 59 Saddler Lane West Barnstable Owner: Jeff Lena Date of Inspection: 4/4/2002 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 je!f 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 and overloaded or clogged SAS or cesspool _ LA Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow < Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Z Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is 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 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.] _i/c(Yes/No)The system fails. I have determined that one or more of the above 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 _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 er supply the system is located in a nitrogen sensitive area(In elihead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Secti the system is considered a significant threat,or answered "yes"in Section D above the large system has ' ed.The owner or operator of any large system considered a significant threat under Section E or fail , der Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should co the appropriate regional office of the Department. r agv J vi i i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 59 Saddler Lane West Barnstable Owner: Jeff Lena Date of Inspection: 4/4/2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: I I 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 than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location f the o Soil Absorption System SAS on the site has been determined based j'P Y (SAS) on: Yes No _Z/_ Existing information.For example,a plan at the Board of Health. i Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) rage o of i i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 59 Saddler Lane West Barnstable Owner: Jeff Lena Date of Inspection: 4/4/2002 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: 3 _ Does residence have a garbage grinder(yes or no):f1/0 Is laundry on a separate sewage system(yes or no):AM[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):_yg - 000 NfRr (qqo I,PO) Water meter readings,if available(last 2 years usage(gpd)): 2o!L OW j yc Ar Sump Pump(yes or no): vvo ",STI »M M4 2AtiLcpr101V s 0afr2% Last date of occupancy: cv,Lnrr�T COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Rd = Basis of design flow(seats/persons/sgketc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 s effi(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(descri GENERAL INFORMATION Pumping Records Source of information: OwN e m -0 to 70),'; PrMP� w I�; wr3 cb✓ SYsr�,� wAs REpzRc to Was system pumped as part of the inspection(yes or no): '� s If yes,volume pumped: I 00ro allons--How was quantity pumped determined? 6Ru4d tl"e Reason for pumping: /t9lJi'nr &-4rlcr TYPE OF SYSTEM ✓geptic tank,distribution box,soil absorption system Single cesspool r_Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: DisT^rXvT&,,) Bo,,t Aw0 trAcHCLe-c/J 7—MMA111V 199& Were sewage odors detected when arriving at the site(yes or no): L i rags / u► 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 59 Saddler Lane West Barnstable Owner: Jeff Lena Date of Inspection: 4/4/2002 BUILDING SEWER(locate on site plan) Depth below grade: W / Materials of construction:_cast iron ri40 PVC_other(explain): Distance from private water supply well or suction line: L /0j Comments(on condition of joints,venting,evidence of leakage,etc.): IYo e✓ onyecf a1F IiAktyzi.. SEPTIC TANK: ;✓(locate on site plan) Depth below grade: Y6 x Material of construction: ✓concrete—metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: i.;' ,z y.s" ,c y.s-' Sludge depth: b Distance from the top of sludge to bottom of outlet tee or baffle: 14, Scum thickness: to" Distance from top of scum to top of outlet tee or baffle: y u Distance from bottom of scum to bottom of outlet tee or baffle: qr How were dimensions determined: yrp,rle y- o b rApe mnssv^-e Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): exlnP TANLI M JVty a -3 YeArs. S7hew/L�� P,ccv nn t"9Wr)Cn zN,SSA//rn// RLSd"nS o,✓ T iu-? Aw^ DvrL l- G oss wo Gxzwc Gout'ls 1- WLY Nity 6 ' �F 6�A©�, Cussorr,�� Od'CGL,vtr� GREASE TRAP: (locate on site plan) Depth below grade:— Material of construction:_concrete_metal fiberglass Tpolyethyle other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee affle: Distance from bottom of scum to bottom outlet tee or baffle: Date of last pumping: Comments(on pumping rec mendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet' ,evidence of leakage,etc.): t, r a uF,v�s va a a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Saddler Lane West Barnstable Owner: Jeff Lena Date of Inspection: 4/4/2002 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on plan) Depth below grade: Material of construction: concrete metal_fiberglass ylene other(explain): Dimensions: Capacity: gallons Design Flow: gall ay Alarm present(yes or no): Alarm level: Al working order(yes or no): Date of last pumping: Comments(condi ' of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 011 Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): IUd S1'emc OP e.L>— t/1P PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,con n of pumps and appurtenances,etc.): t i • l ar,V 7 V. .. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Saddler Lane West Barnstable Owner: Jeff Lena Date of Inspection: 4/4/2002 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓leaching chambers,number: 41 W 9b tnpAcitY leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on sit ) 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 i (yes or no): Comments(note condi ton 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,si of hydraulic Failure,level of ponding,condition of vegetation,etc.): t� Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION(continued) Property Address: 59 Saddler Lane West Barnstable Owner: Jeff Lena Date of Inspection: 4/4/2002 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. .F oLK W RLL t 1 act uc,�p y Q ; f — i 1 t 4 ( i f1 C y _Z 31 7 u I AD - -3a' 130 - G A e" _ 3 6 Tor w a, ._ J rage 1 I of I i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Saddler Lane West Barnstable Owner: Jeff Lena Date of Inspection: 4/4/2002 SITE EXAM Slope Surface water / Check cellar Shallow wells Estimated depth to groundwater 612, feet Please indicate(check)all methods used to determine the high ground water elevation: t/Obtained from system design plans on record—If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: No. j Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for 30i!5pogal *pgtem Construction i3ermit Application for a Permit to Construct( )Repair( )Upgrade(),,�Abandon( ) ❑Complete System /54tdividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ' Type of Building: Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow -- - 0 gallons per day. Calculated daily flow ��i gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ,fit i r Type of S.A.S. Description of Soil V S � Nature of Repairs or Alterations(Answer when applicable) _-Z7V-ST4- PIc cFct �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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee Bo Signe Date Application Approved by Date CJ- Application Disapproved for the following reasons Permit No. Date Issued e"e No. �?? J�. Fee l a computer: � THE COMMON�a4l��4L�Fl OF MASSACHUSETTS Entered in com p ' PUBLIC HEALTH,DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yesti - Application for 3W5po.5af *proem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade¢ Abandon( ) ❑Complete System/individual Components Location Address or Lot No.�� n Owner's Name,Address and Tel.No. C.� J Assessor's Map/Parcel /. 4 U�� �� r _! j _ "; a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms�_ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow :�:3--?,ep Fgallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank c 1 _Type of S.A.S. , r? `r Description of Soil n . o Nature of Repairs or Alterations(Answer when applicable) �7x..S`T Its �` 0 i Z In- o - - Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss 's Bo�grfe Stg Date Application Approved by!Ak Date 77-/0 -Ar Application Disapproved for the following reasons Permit No. 3 Date Issued THE COMMONWEALTH OF MASSACHUSETTS 1 BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by N e- at � has bee constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 7H 113) dated '7 l -h� Installer Designer The issuance of this permit shall not be construed as a guarantee that the syst ill functi a designed. Date - Inspector j ——— —No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 0i.9potal 6pgtem Construction Vermit Permission is hereby granted to Construct( )Repair )Upgrade( )Abandon( ) System located at � j ,P 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 permi ( _Date: 7-/U -} J' Approved by - 9 TOWN OF BARNSTABLE (, ✓ LOCATION 5 coI SEWAGE # �0 VII,LAGE �_ W ASSESSOR'SIMAP & LOT /sl—0&y INSTALLER'S NAME&PHONE NO. 1 A Co,r)e ! C7Coi c, SEPTIC TANK CAPACITY 1 Q� C a / LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER O OWNE Al 7Z PERMTTDATE: 7 10-2 2' 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 01 Furnished by s.A 1438 a - � ,r r oa t' TOWN OF BARNSTABLE G SEWAGE # LOCATION ��.� - 1�'`' � � �,/lam. VII.LAGE '--ASSESSOR'S MAP & LOT �.Sj-0 INSTALLER'S NAME&PHONE NO. I SEPTIC TANK CAPACITY nQ2 / too A, LEACHING FACILITY: (type) NO.OF BEDROOMS 3 i BUILDER O OWNE � �"'�d PERMIT DATE: - —10 � � COMPLIANCE DATE: 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) d l � Furnished by .� I Q e er r a L . 1 G C� Q 1 Commonwealth of Massachusetts Title 5 Official Inspection, Form ! 1 Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments r'.� 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name information is W Barnstable ..AA required for every �rl MA 02668 4-2-21 t r page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information 5.1 4'15 331 Shawn Mcelroy Name of Inspector - Upper Cape`Septic Services Company Name P.O. Box 73 I. f Company Address East Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my'training and'expenence in the proper function and maintenance of on-site'sewage disposal systems'After conducting this inspectional have determined that the system: ` 1. ®' Passes 2. ❑ Conditionally Passes 3. .❑-Needs Further,Evaluation by,the Local Approving Authority 4. ❑ Fails 4-2-21 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 L I Commonwealth of ell' Title 5 Official Inspection*Form" -_ ' .,�. 01 h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name information is W. Barnstable ��'' MA 02668 ; ;• 4-2-21'' required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary . ;` .• e. 7 } } ,'i.. ' t"It Y h_ 1 r7E•''t a..,1+- f .. Inspection Summary:+Complete 1; 2, 3, or 5 and all of 4 and 6. t,_r 1) System Passes: ® 1 have not found any information which indicates that any of therfailure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: .4 System is in good working order with no sign of failure. , + • : t . - `2) ' Sysrtem Conditionally'Passes: . . -. ❑i7One+ '`t y - ' • ` W or more system components as described in,the"ConditionalPass"section need to be .. , replaced or repaired-The system, upon completion of the replacemen�,t or repair, as approved by the Board of Health,wi111pass. r Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound,,not,leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N t❑ ND (Explain below): .P� {k`-d+ t:rtt; :.fi. :# .. .... ?. t... y f• � >Fa i.. _. ? rt L t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts t Title 5 Official. Inspection-Foft" , YiQ Subsurface Sewage Disposal System Form-..:Not for Voluntary Assessments t-: 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name information is required for every W Barnstable MA 02668 4-2-21,, page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ir.. 2) System Conditionally Passes (cont:): El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if l' pumps/alarms are `repaired: ❑ Observation of sewage backup or break out or high-static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ' ' ❑' broken'pipe(s) are replaced ❑ Y ❑N ' ❑.ND (Explain below): ❑ ' ' obstruction-is`removed `' ' " I ❑ Y ❑N ❑ ND (Explain below): ❑"'� distribution box is leveled or replaced ❑Y ''D N`: ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required,by the Board of Health: ❑ Conditions exist which require further,evaluation by,the Board of Health in order to determine if ttie'system is failing to protect public health, safety or the environment: ' a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ;y Title 5 Official Inspection Form d p: i t Subsurface Sewage Disposal Systern'Form -'Not for Voluntary Assessments t .•+ x� 59 Saddler Ln / Property Address George Kelloyan r :F '• .r. Owner Owner's Name { information is MA 02668 4=2-21• •• required for every W. Barnstable r _: f page,. City/Town :e, , _ State Zip Code Date of Inspection C. Inspection Summary (cont.) � a� ❑ Cesspool or privy is within 50 feet of a surface water•' F- ❑ ' Cesspool or privy Is within 50`feet of a bordering vegetated wetland or a salt marsh - r 1 y b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, vl,f safety and environment: „ , ,' ❑The system has a septic.tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface wiater supply or'fributary 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. }• p .t ,,,[]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 weil**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. .i. c. Other: ,. �, , , s r `d • S a I�a .f { ., ;A'l. 1 c [ ° 4) System Failure Criteria Applicable to All Systems: ., You must indicate "Yes"'or"No"to each'of the'followin•g for all inspections: ,,Yes No ,,1 ❑ ® Backup of sewage Into facility or.system compone nt due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts r4a Title 5 Official Inspection,n .Form- • ` � N Subsurface Sewage Disposal System Form -;Not for,,Voluntary Assessments 59 Saddler Ln J Property Address George Kelloyan Owner Owner's Name information is _ •.r• required for every W. Barnstable MA 02668 4-2=21 4 page. City/Town . . State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.), .. •fly � _, . ' Yes :No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below,invert or available volume is less ❑ ®° "` than Y2 day flow ` ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS; cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a•public water supply ❑ well. ❑* ® Any portion of a cesspool or privy.is within 50 feet of a private water supply well. J f ❑ ®' Any portion'of a cesspool or.piivy.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 % -•,y _ and chain of custody must be attached to this form'.], ❑ ® The system isra cesspool serving a facility with a design.flow of 2000 gpd- F '10,000 gpd. ' The'system fails:l have determined that one or more of the above failure El ' '`®✓ 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. 1, . 5) Large Systems:To be considered a large system the system must serve a facility with a design t flow of 10;000 gpd to 15,000 gpd. t ` For large systems, you must indicate either"yes'.or"no'. to_each of the following, in addition to the questions in Section CA. _ , . Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ►yi' Title 5 Official, Irispection. Fora P Subsurface Sewage Disposal System Form'-Not forVoluntary Assessments 4.; >' 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name ' information is required for every W. Barnstable 01 A MA 02668 4-2-21 € ` � page. City/Town ' State Zip Code Date of Inspection C. Inspection Summary (cont.) ` ► �. . If you have answered 'yes"tolany"question insSection C.5 the system is considered'a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat-under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional'office of the Department. _ 6. You must indicate "yes" or"no"for each of the following for all inspections: r € Yes No ,. �:' i t { . €• f,. , . I' 0 .!f v❑. o•Pumping information was provided by the owner, occupant, or Board of Health .❑ ® Were any4of the.system components pumped out in the previous two weeks? ` ' ® ' I ❑ 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 t �:• . ❑ ' , : '® `� ' this inspection? • ., . 3, _• . _. Were as built plans of the system obtained and examined? (If they were not -❑ available note as N/A) 1 ,R Was the:facility or.dwelling inspected for signs of sewage back up? • . r./ llt IF3 � .. � 1 � tY.s j 'f a� .9 � i `'�1 i> ♦1 .. .[:19 A. LTV - 1 y : '' +<®� ,,. ;❑ s? : Was thesite inspected-for signs of break out? 01.; ❑ Were all system components,''excluding the SAS, located on site? ® ❑ Were the septic tank man holes.uncovered, opened, and the interior of the tank inspected for the condition of the baffle's or tees, material of construction, S ` dimensions, depth of liquid,'6pith of sludge and depth.of scum? r®r ❑ Wasthe facility owner�(and,occupants if different from owner) provided with information'on the'proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑' Existing'information. For example, a,plan at•the Board of Health. `❑I . 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)] r� r t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts , ;1 f Title 5 Official Inspection- Form ' IQ Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments •• 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name information is W. Barnstable MA 02668 4=2=21 required for every • - page. City/Town State Zip Code Date of Inspection D. System Information ; , 4 >.'7 1. Residential Flow Conditions: _ . , Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd.x#of bedrooms): 330 Description: ,J, s Number of current residents: + 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry,system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: ,, • 4-2021 Date t5insp.doc•rev.7/26/2018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts I�l• Title 5 Official-. Inspectio ' Form - 4 Subsurface Sewage Disposal System Form=Not fortVoluntary Assessments vt 59 Saddler Ln 'r Property Address George Kelloyan tr Owner Owner's Name information is W. Barnstable r required for every MA 02668 4-2-21 page. City/Town' State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: 'W�':� - r I- - i 41. Type of Establishment: Design,flow(based on 310 CMR 15.203): ' Gallons per day(god) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? "I ❑ Yes ❑ No _ Non-sanitary waste discharged to the Title 5 system? , f "f; a' ❑ Yes ❑ No Water meter readings, if available: 1`• _ Last date of occupancy/use: Date Other(describe below): _ it e 3. Pumping Records: Source of information: Owner----pumped 1-2021 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official. Inspection :Form'. A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '. 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name information is required for every W. Barnstable MA 02668 4-2-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ f�re - . g •,r a.>! -4 E 4. Type of System: I ® Septic tank, distribution box, soil absorption system , ❑ Single cesspool El.- Overflow cesspool ❑ Priv y ❑ 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): r. Approximate age of all components, date installed (if known) and source of information: 1998 Were sewage odors detected when.arriving at the site? r ❑ Yes ® No 5. Building Sewer(locate on site plan): 30" Depth below grade: ` feet Material of construction:' _c ® cast iron E1 40 PVC " ❑ other`(explain):' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �. t' :. <--. I .. :► ;. Title 5 Official. Inspection Fori +,1. , I it Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments," ` 59 Saddler Ln - Property Address - George Kelloyan !' Owner Owner's Name information is Barnstable MA 02668 4-2-21�, f required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) � .. : 6. Septic Tank (locate on site plan): T Depth below grade: r , i . . : s 2411 fe - 9 et Material of construction: i ® concrete ❑ metal ❑ fiberglass, ❑4polyethylene ❑ other(explain) If tank is metal, list age: : t e r ;r years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" Distance from,top of sludge to bottom of outlet tee or.baffle= 20 Scum thickness Distance from top of scum to top of outlet tee,or baffle. 6" 14" . Distance from bottom of scum to bottom of outlet tee or baffle - How were dimensions determined? Tape e Comments (on pumping recommendations, inlet and outlet tee or,baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc'.): Tank is in good condition with baffles-installed and no sign•of leakage. Recommend pumping for solids. t5insp.doc•rev.7/26/2018 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form VA �► Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments .. r y `d 59 Saddler Ln Property Address t George Kelloyan Owner Owner's Name information is W. Barnstable MA 02668 4-2-21 required for every page. Cityrrown • State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: , ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene _ ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: , . r I ' 4 Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: I� Capacity: gallons I Design Flow: gallons per day t5insp.doc•rev.7P18t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 i Commonwealth of Massachusetts -1' Title 5 Official Inspection Form ?-I dab. Subsurface Sewage,Disposal System Form -Not for,Voluntary Assessments 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name - information is required for every W. Barnstable r MA 02668 4-2-21 page. City/Town *."• State Zip Code Date of Inspection D. System Information (cont.) - 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: , ❑ Yes ❑ No t , Date of last pumping: `Date- Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9'. Distributiontox'(if present must be'opened)'(locate on'si4e plan').- Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. r • A )I t5insp.doc-rev.7/26/2018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts f Title 5 Official , Inspection Fora - ? A Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name information is required for every W. Barnstable MA 02668 4-2-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): a Pumps in working order: ` ., ❑ Yes ❑ No* Alarms in working order: " ❑ Yes' ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a.conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: T Type: ❑ leaching pits ' number: ® leaching chambers number: 4-Infiltrators 11 x24 x2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts c ,, •<< Title 5 Official- Inspection Form , i�i. Subsurface Sewage Disposal System Form,=Not-for Voluntary.Assessments ��• 59 Saddler Ln Property Address George Kelloyan � Owner Owner's Name information is required for every W. Barnstable _` n MA 02668 4-2-21 . page. City/Town , State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) `11164 Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation ; , etc.): " Infiltrator leach field in good working order and empty at inspection with no sign of back-up into d-box ` or surrounding stone. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth--;top of liquid to inlet inveit> �►� ,t, �` Depth of solids layer ;_, 74 Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes f ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts - - f Title 5 Official Inspection Form m Subsurface Sewage Disposal System,Form -'Not for Voluntary Assessments- ' J_Jti � 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name information is W. Barnstable r.' , MA 02668 4-2-21 i required for every • page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 13. Privy(locate on site plan): - r Materials of construction: t IT Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts 60 Title 5 official. lhspection .Form Y -Il Subsurface-Sewage Disposal System Form -Not for Voluntary Assessments i 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name information is required for every W. Barnstable MA 02668 4-2-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties tout leaiftwio permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ` ❑ drawing attached separately V. f r 3F4 4 36 r� t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , J<<: 59 Saddler Ln Property Address George Kelloyan Owner Owner's Name information is required for every W. Barnstable MA 02668 4-2-21 + - page. City/Town State Zip Code Date of Inspection D. System Information (cont.),;, , s . . . 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar t ❑ Shallow wells ! , Estimated depth to high groundwater: 124 feet Please indicate all methods used to determine the high groundwater elevation:. ® Obtained from system design plans on record ', - If checked, date of design plan reviewed:-, -•.. Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) El Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 t Commonwealth of Massachusetts } <: rvi i.ii Title 5 Official. Inspec-tior . Form` i ; � Subsurface Sewage Disposal System Form :Not for Vol untary+Assessments 59 Saddler Ln - Property Address George Kelloyan Owner Owner's Name information is W. Barnstable .:� MA 02668 4-2-21 required for every " page. City/Town " State Zip Code Date of Inspection E. Report Completeness Checklist fl ' . t, ! j # - . °ti t Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. - ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate �~ 4 (Failure Criteria) and 6 (Checklist) completed, j ® 'D. System Information:i I For 8: Tight/Holding Tank—Pumping contract,attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15:Explanation of estimated depth to high groundwater included j. �. 1`, r,f Ir. .. ... .."i ! 1-1 it t 4 r' . : . 1., . A a r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 - SECTION - SEWAGE .:``' • -SEPTIC TANK- -"D"BOX - g -LEACH TOP OF QI]N r i' (MSL)M `-"2"OF reTO rh" WASHED STONE t Jn r11'Y)i 1'1 I) COVG< ! Ze,o l58 WT OUT IN• l OUT• IN• � "z 6 9 � �0 TIC �- I ro TANK l3�j.�{3 iO l �7Q1{'� ELEV. ELEV. ELEV. ( �11 ELEV. b2hu? t 138,33 138,l0 21 21 l(off E�LEV. ELEV. _ OF Va"-lrh"1 �n WASHED STONE I:J� �. TOTAL r t l 5 5tg \ . TEST HOLE LOG TEST BY t WITNESS TEST DATE r�2 Co I e DESIGN BEDROOM HOUSE pr, ELEV. I QZ ELEV. i NO I rr `-�� — DISPO5E.R DISPOSER II � a PERC RATE MINAN. �\ )4�o FLOW RATE Z-ZT (GAL./DAY) I �� _ I4-z SEPTIC TANK 'Zc� ({, _ ��C� I4Z� - � _ 9' 'I µ REO'D`SEPTIC TANK SIZE �Qn �°�- �z _ Lp� l JiN 14-Z � IU•�Q��' LEACH FACILITY K ,o SIDE WAL /t2a 4 7 r! 01 251 r G/D: p l't . ( BOT'TOIUI U!?1,V?7L =-78,5 (U.e� p 60,2 G/D. JI h' TOTAL 2.P4,2C7 = �..�;�(�, 6 �s�.D .'. .I --=-- �- 14(1 ►5Co I2q , 'co t' _ -- USE: LEACHING �I lo' �cxIyE vr�.Nt x ��>✓r-->=-t.—�:=r.:i ,, �; � t 'WATER ENCOUNTERED NOTES (UNLESS OTHERWISE NOTED) 1.DATUM(MSL)f TAKEN FROM �-`'��r�"J' i}QUADRANGLE MAP - SETf3b-c1 JrJ' �d ��I�LiGT�c�I� -f-I 2.MUNICIPAL WATER I oVAILABLEQ}-�T 3.PIPE PITCH:Sill PER FOOT ' 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- -44 - 7r 5 '11010, 5.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. �OS� Of �'!� �, Cj 1 --� 7,�I M 1 r) 6.PIPE JOINTS SHALL BE MADE WATER-TIGHTJ ( 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. AF1 H ; STATE ENVIRONMENTAL CODE TITLE 5 PLAN . . -• LOCUS: 5 T 4�/a �n P' 1_f -.11-- "Cr li= USED POD_ .�ZO .L�`f l_.�.1G �rd��+.�.G> !b rnt - - - _ .. _ n ,� �Ii -F`�N 0f -Mq�. �� E u $� — 3y` T_5Ae 1�'(4\ REG.PR Al �`�10� eR - ARNL REF: h FZ down cape engineering m 2fi 48 PREPARED FOR: CIVIL ENGINEERS r 4 ' - �EV, Q/�e r LAND SURVEYORS - ✓/c7 BOARD OF HEALTH RE V R I I CONTOURS (EXISTING)--•---------- 9" .ti/1�..• SCALE _ . _ ` 4-� I d- IF _ (PROPOSED)-O-O�-O- APPROVED DATE MA �. DATE