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HomeMy WebLinkAbout0030 STEERE WAY - Health (2) ' �O Steere Wa Y Tvlarst-caas wi lls s A= 149 157 ; i l i i I' I Commonwealth of Massachusetts +� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments h c � 30 Steere Way v Property Address Nataliya Maduro Owner Owner's Name information is Marstons Mills MA 02648_._ 03/29/2021 required for every '`����} page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 51�t 153a(v on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road 4:1 Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 03/30/2021 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 � v r the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 5 bedroom home has a heavy top 1500 gallon septic tank with a D-Box feeding 2 precast leaching pits with stone. At the time of the inspection no visible failure criteria was found. 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): s t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form I- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR ' 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way L� Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is Marstons Mills MA 02648 03/29/2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in'addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply I ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way V� Property Address Nataliya Maduro Owner Owner's Name information is Marstons Mills MA 02648 03/29/2021 required for every page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ 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)] i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Steere Way v— Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 6 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 plus GPD Description: Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: In 2020-32,000 gallons were used and in 2019 -3000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form Not for Voluntary Assessm As sessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is Marstons Mills MA 02648 required for every 03/29/2021 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) I Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 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: 10/21/1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 9' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 8' 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: Heavy Top 1500 gallon Sludge depth: 4 Distance from top of sludge to bottom of outlet tee or baffle 32 Scum thickness 4" 'i Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? 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.): recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5.insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 _ page. Citylrown 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: 2 ❑ leaching chambers number: ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. Citylrown 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.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 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 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 I ism�accc� R- -ve rs,yl� s-�otir 1 3'-/�nSrty✓E �i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet 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: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Steere Way V� Property Address Nataliya Maduro Owner Owner's Name information is required for every Marstons Mills MA 02648 03/29/2021 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1 2 3 or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 L Commonwealth of Massachusetts -/i�N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 30 Steere Way Property Address Standish Owner information Owner's Name F-a is required for z every page. `'--' , Marstons Mills MA 02648 4/27/18 1 Cityrrown State Zip Code Date of Inspection W f w�7 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 54- 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536- City/Town State Zip Code, 508.272.6433 13010 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/27/18 Inspector's Ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 L_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No 0 ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 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 d to 15,000 d. 9 9p 9P 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 mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 6 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2016 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped within 3 yrs per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doo•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1988 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 8' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 7'6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 septic tank per state code should not be deeper than 4' If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: trace t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness trace Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 years to prolong the life of the system 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M a 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M ,••�''r 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was not located, probing gives no indication that the cover is raised to a reasonable depth Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 1 }i t.r,. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments M ' 30 Steere Way Property Address Standish Owner information Owners Name is required for every page. Marstons Mills MA 02648 4/27/18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2 600g leach pits, pit C was excavted, it is 8' below grade, bottom at 12', cover raised to 12" of grade, dry at this time, pit D was not observed 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 t Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'M 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3 2- � D t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet 5 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: 1988 NGW 156" Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: 1988 compliance on file ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Pit is dry at this time bottom at 12', 1988 plan says NGW 156", previous insection by Bortolotti Construction estimated gw at 18'with and adj to 14.5, based on these the system may be within the 4'seperation to gw Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s 30 Steere Way Property Address Standish Owner information Owner's Name is required for every page. Marstons Mills MA 02648 4/27/18 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 C _ ' 7% Fee----` --` BOARD OF HEALTH TOWN OF BARNSTABLE AppiicationArVell Con0ructioni3ermit Ap lication is here made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel ------------------------------------------------- -- ------------------------------------------ s� a Owner Address -- ------ - -- j �- 36. ---- 6 -SU ado Installer — Driller Address Type of Building Dwelling------ ----------------------------------------------- Other - Type of Building ---------------- No. of Persons----------------------------------__-______ Type of Well- - —� SG�- ------ - Capacity------------/ --- Purpose of Well--------Z---�-------------------- — --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Heal Private Well P to i egulation - The undersigned further agrees not to place the well in operation un ' a er 'fi as been issued by the Board of Health. Signed date Application Approved By -- h -- ------------------------------- �-� 2`S'-- 05 --------- -------=----- date Application Disapproved fo the following reasons:---------------------------------------------____________—__—__________ -----------—-- —___—__-- --- - ------------------------------------------------------------------------- �11 date Permit No. Y�L—Z60 - v�d- -------------------- Issued--- - ^d�� - - - ------------------ date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS IS 'I�RD§CERT FY, Th It the Individ al Well Constructed (Altered ( ), or Repaired ( ) -------- by- c � - - Installer P at- - -- -�'�,i�?1­------x-__/--- ------------------------------------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ------------------------Dated------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---------�-- a ----------------- -- Inspector------------------------------------- ? , 4. ��-20 0_�- 6 3 � � � Fe _S.�.�- No. BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rVett Conotruct ion Perm' it Ap lication is herellnmade for a permit to Construct ( ), Alter( ), or Repair ( )'anindividual Well at: - `�-�----s �Vie-�'� -- -�9�-�G� _--�����✓__�___!��--_----------- Location — Address Assessors Map and Parcel --------------------—-----—--— — — --- -- --- ------— ----- ---—--- — —---------- '` Owner re dd A ss Installer — Driller Address j Type of Building Dwelling------—------------------------------------------------------- Other - Type of Building ------ No. of Persons----------------------------------__________ Type of Well- Ca acit l� Purpose of Well-------- --------------------------- s fAgreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well P to ti egulatiorf - The undersigned further agrees not to place the well in operation un 'Ter 'fi f C n as been issued by the Board of Health. Signed d p. date Application Approved By 4 i -�- U� f --- --------------------------------- date Application Disapproved fo the following reasons:-------------------- -- date j Permit No. o o _'- C� ----- - - - 7----Z-V- v-F' - - --------------------- -- - — - - Issued------ date -----------------------------------------------------------------------------------"'--------------------' 4 BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO �eERT FY, That the Individual Well Constructed (4/j Altered ( ), or Repaired ( ) 1� _��v --------------------------------------------------------------------------------------------------------- Installer at- � 7-7---x�/7_1i Ll�s------------------------------------------------------------------------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------------------------Dated-------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL I SYSTEM WILL FUNCTION SATISFACTORY. " �a� -- Inspector------------------ ' DATE-------------------------------------------------- ----------------------------------------------------- -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Melt Congtruct ion Permit - s No. —-'---- �'-Ca �, Fee------1-------- A:: Permission is hereby granted- :¢ 'iC/-�a--------------------------------------------------------------------- to Construct (VT Alter ( ), or Repair ( ) an Individual Well at: ---------------------------------------------- Street as shown on the application for a Well Construction Permit �+ No. ------------------------------- - ------------------------------------ - Date/- ------ Z /-�;2 --- --- ------- ------ - - -------- -- - ------ ---------- -- - -2 ^ 2 S-o Board o ealth DATE-- - - --- - —— - -- Commonwealth,of Massachusetts W Title 5 Official Inspection Form:_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Own is information is �,/n /� �i ,,�y, 2-0 required for / every page. Ctty/, State Zip Code Date f Inspection Inspection results must be submitted on this form.Inspection.forms may.,not.be altered in any way. Important: men ffllingout A. General In formation` forms on the �— computer,use 1. I, actor: only the tab key to move your cursor-"do not N ,e,oftnspector.. c- c use the return key. Uq Umpany Name o..pany ddress �CittyyfToown ^� (� State Zip Code D�: C, vTelephone"Number License Number rl) 17— _ I -B..C.6 tification - 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 16.340 of Title 51(310 CMR 15.000).The`system +d'Passes El Conditionally Passes Fails RA Needs Further Evaluation by the Local Approving Authority Insp tor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health.or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to.the appropriate regional office of the DER 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: l5insp.do6-08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 15 . Commonwealth of.Massachusetts _ Title 5 Official Ins ecl Ion Form p Subsurface Sewage Disposal System Form of for Voluntary Assessments P19p3rty Address ° Owner O n is Name information is required for every page. City/Town State Zip Code Date of Inspection B. 'Certification (cost.) Inspection Summary: Check A,B;C,D or E/always,complete all of Section D: ;,_ A) System.Passes: [W] I have,not found any information which indicates that any of theVfailure.criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below: Comments: B) System Conditionally Passes: ❑ One.or more system components.as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health', will pass. Answer yes, no or not determined (Y, N;.ND) in the ❑for the following!.statements. if"not determined,"please explain. ❑' The septic tank>is metal and over 20 years old*or the septic tank(whether�metal or not) is structurally unsound, exhibits substantial infiltration or exflltration or fankfailure`is imminent. System will pass..inspecton 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): . El broken pipe(s) are replaced: ❑ obstruction is removed '15insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of IS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Furm Not for Voluntary Assessments P pe y Address Owner Own r s arm information is required for i every page. Ci frown C State Zip Code Date of l lspec ion B. Certification .(cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken orobstructed 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 aseptic 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.. t5insp:doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 i Commonwealth of Massachusetts = Title 5 Official nspection Form Subsurface Sewage Disposal System,Form :Not for Voluntary Assessments rp erty Andress Owner O n is Name information.is � ��///J� /j�n required for J�/l<V/ /-c/� every page. CityfTown State Zip Code Date of Inspection S. Certification (cont.) C) Further Evaluation is Required by the Board.of Health (cunt.):. ❑ .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 copyof the analysis must be attached to this form. I.Other: D): Systemfailure Criteria Applicable to AIPSystems: You must indicate"Yes"or".No"to e.ach,.of the following forall inspections: Yes No El d Backup of sewage into facility or system component due to.overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded:or clogged SAS or cesspool El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged.SAS or cesspool Liquid depth in cesspool-is. less than 6"below`invert or•availabl.e volume is less El than%dayflow ElRequired pumping,more than 4 times in the last year NOT due to clogged or Ed 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. t5insp.doc•08/06 Title 5 Official inspection Form:Subsurface Sewage Disposal System'-Page 4 of 16 Commonwealth of Massachusetts. Title 5 Official ln., tion Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a> y Address Owner O e s Name information is �. 0 required for � every page. CitylTown State Zip Code Date of Inspec4ion 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. ❑ Ed Any portion of a cesspool or privy is less than.100 feet but greater than 50 feet from a private water supplywell with 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.] ❑ d The system.is a cesspool serving,a facility with a design flow of 2000gpd- 10,000gpd. ❑ I/ The system fails.,l have determined that one or.more of the above failure critena.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 10000 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5insp.doc•08/06" Title 5 Official Inspection 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 PFo y Address Owner wn r s Name information is rn ( - required for Lao. �`"l/l D�70 /U Cit Grown State Zip Code Dat Hof Ins i n every page. y., P e pest o C. Checklist Check if the following have been done.You must indicate"yes'.or'"no"as to each of the following: Yes . No 0. Pumping information was provided by the owner, occupant, or Board of Health 0 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 El' this;insp.ecti.on?: Were as.built plans of the system obtained and examined?(If they were not ave lable:notelas N/A) (, Was the.facility or;dwelling-inspected for signs of sewage backup? . E] Was:the site inspected for signs of..break out? Q_/ .'❑ . 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? j� 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 any of distance,is unacceptable) [310 CMR 15.302(5)] Mnsp.doc•08106 .. _ - Title 5 Official Inspection Form:Subsurface Sewage-Disposal System-Page 6 of 15 Commonwealth of.Massachusetts Title, 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , P e y Address Owner Ow is Name // information is ,{ /Q � ��,7 /46� required for C7/ every page. CitylTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms.(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (a Number of current residents: 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 2---No Seasonal use? ❑ Yes No Water meter readings, if available'•last 2 ears usage(gpd)): 9 ( Y 9 Sump pump? ❑ Yes Lh No Last date of occupancy: (- e � �L"� Date Commercial/Industrial Flow Conditions: Type of Establishment: i n based on 310 CMR 15.203 Design flow( ) f : 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): t@insp.doc-08106� Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts y, Title 5 Official In ection Form. p Subsurface Sewage Disposal,System Form-Not for'Volunfary Assessments Property Address U , Owner Own is Name information is required for every page. City/Town State Zip Code Date of Inspection = D. System Information (cont.) General Information ,:Pumping Records: • Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,,volume pumped: ,gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic:tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool` Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative.:technology.Attach a copy of the current operation and maintenance contract(to'be obtained from system owner) ❑ Tight tank.,Attach a.copy of.the.,DEP approval. . ❑ Other(describe): Ab proximate age of all components,,date installed (if known) and source of information; Were sewage odors detected when arriving at the site? ❑ Yes CtJ�N0 t5lnsp.doc-08(06 Title 6 Official Inspection Form Subsurface Sewage-Disposal System-Page 8 of 15. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments O. Pr perty Address Owner Own s ame �n information is (( � f�4 required for �M/U /' Y /Q �`7.C�f�toalov? every page. City/Town ( 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 line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site'plan): Depth below grade: , RU feet Material of construction: concrete El 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) D Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? t5insp.doc-0a(06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 15 . Commonwealth of Massachusetts 1 Title 5 Inspection,Offida[ _ Form Subsurface Sewage Disposal System-Form Not for Voluntary Assessments.. ., o erty Adgress (/ Owner w is Name / information is , / �v „ required for _ 1 every pa OQ page. City/ own% State -Zip Code Date of Inspection D. System .Information (cont.) Comments.(on,pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,. . liquid levels as related to outlet invert, evidence of leakage, etc.): . Grease Trap(locate on site plan): /Y� 0 Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from to .of scum to to of outlet tee or baffle P P 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): 1X O Depth below.grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene. ❑ other(explain): l5insp.doc•08/06 Title.5 Official Inspection Form;Subsurface Sewage Disposal System•Page 10 of 16 Commonwealth of Massachusetts Title 5 Official"Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pr p rty Address J Owner Owe s Name information is U required for n every page. Cityi I own State Zip Code Datd of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions::_ _. . .w 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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No . Alarms in working order: ❑ Yes ❑ No t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 1s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.'Disposal System,Form-Not for Voluntary Assessments 20 C Pope y Address RA Owner �w er's Name information is required for every page. Ci y_57U' .. 7 7 State Zip Code Date of Inspdction D System Information (cont:) Comments(note condition of pump chamber, condition of pumps and.appurtenances,etc.): ..Soil Absorption System(SAS) (locate on site.plan,.excavation not required):. If SAS not located, explain why: Type - leaching pits number: ❑- leaching chambers number: ❑ leaching galleries.. .. number: leachin trenches number,.len th:.,.. ❑ g 9 ❑ 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.): t5insp.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 1operty Ad,iress Owner s Nam information is .required for C�— every page. C ty own State Zip Code Date of Ins ection D. System Information (cont.) "Cesspools,(cesspool must be pumped as part of inspection) (locate on site plan): U 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 s of hydraulic failure level of ondin condition of vegetation, condition of soil sin h Comments note co p g, g , ( 9 Y etc.): Privy(locate on site plan): A/0 Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc..): t5insp.do6.•08/06 Title 5 Official Inspection Form:Subsurface'Sewage Disposal System•Page 13 of 15 .s Commonwealth of Massachusetts Title 5 Offiicial.,lnspection Form Subsurface Sewage Disposa. System°Forms-i 'o 'for Voluntary Assessments Al 6(2ew pperty Address (/ Owner Ow er's Name information is n �t p required for ,_e�f/ A .- (J =� q , `l�L ._ _ every page. Citylrown State Zip Code Date:of In pection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide.a sketch.of the sewage disposal system including ties to at least'two permanent re ference.1andmarks or benchmarks Locate all'wells,within 100 feet. Locate where public water supply enters the building. Fran of Gk)rn e- I Goot l &,A( k r� c()Uo a110 l5insp.doc•08106 Title 6 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 op rty Address O Owner O n is Name information is �1s� required for /� U every page. City/Town State Zip Code Date al Inspection D. System Information.(cont.) 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 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: 60 V/rez S4-0 , &r 1C�CI l5insp.doc•oa(o6 Title 5 Official Inspection Foan:Subsurface Sewage Disposal System-Page 15 of 15 Permit Number: Date: Completed by: iY HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 50 7`e�i"e U/a � Lot No. Owner: // Address: Contractor: �J C� Address: ,? cz1W !s/5 Y Notes: STEP 1 Measure depth to water table � to nearest 1/10 ft. .............................................................................. .Date month/day/year STEP .2 Using Water-Level Range.Zone and Index Well Map locate site and determine: J ) OAppropriate index well............................ ................. OWater level range zone .......................:..........:.................. STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth toj/ water level for index well ........................... Q7 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level adjustment .................. ' STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water >G/ level.at site (STEP 1) ................................................................................................. ........... ! ! � Figure 13.--Reproducible computation form. 15 Ic afdK a U, eol 4/, Town of Barnstable �pf tHE Tp�� Regulatory Services Bnxxslna Thomas F. Geiler, Director 9$A �9. ••� Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. V ASSESSOR'S MAP NO./eP— /5-_7 PARCEL Eg_-- L-OCAT ION SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S NAME i ADDRESS 8 U I L D E R -OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �zss� � .�"� � �c�� .e:, ,®off -- � � ram( �� i .`\ r /� B 1 � �' 1 � f t No. .........�g r Fic$...... /�..._ - THE COMMONWEALTH OF MASSACHUSETTS p ��9w /BOARD OF HEALTH. ��.w.!.`+'...........OF...... C.l ....................... Appliration for 39iu uuttl Works Tonstrudiun rrrmit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: ^ C e S �� ..,,:1.. ...._.__ ...----.... ..... ............. -- .. - CUBS Q"-�---••--••�...._............. cation .or Lot No. ._.._........... .._ ^a/... .._.....__.. ... ..................._._..... wn Address a .... -----. ��..:............••••--... ........._..-•-......------...._......-•---•----......---....._....---•'•-•---.........._------... Installer Address //�� 5b ...S Type of Building � Size Lot.'�3.. q. feet .. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .................................... W Design Flow---•.--------��.o..:. ..•-----_--gallons perse per cay. Total d7ilylfow.............Y� ........_.... lot�S W Septic Tank—Liquid capactt .gallons Length.lQ.0.... Width_ (42 5.*..... Diameter................ Depth'-I ; x Disposal Trench—No............................. Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..-.....2—.-..... Diameter.....I--Z..... Depth below inlet..5.,.5-7..... Total leaching area..4.910...sq. ft. Z Other Distribution box ) Dosing tank Percolation Test Resul Performed by... I�BAirL...R.6..•..... Date....4Q-1Z T �.r�... .� Test Pit No. 1. .. minutes per inch Depth of Test Pit_.._� ��_ Depth to ground water.._. ..... ._ fs. Test Pit No. 2.___... ...minutes per inch Depth of Test Pit....I. ... Depth to ground water. ...'.-©....... O ................u................. ---•------. --..t+.--- . 4....-------•------.....------------...............---- ._......¢ Description'of So .. D.- -. _.-'.�-�,��--G.�...cQM�sF - .S.T �} d>._5& `--•----•-•--jc�' _c. .------3� l �k� ----------- M --•------------------------- W --------L------------------•-----------------......-.------------------------------------------------------------------------ -----------------------------------.-----------------------------•------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ......................... ..........................................---•--••-•-•------'........--•-----.......-----------------------------------------------...-•-•-•---•--•----•----••-•---.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f the provisions of AITI U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ss d by t bo� of health. Signed . .... .. ................... .WD ..... .... Application Approved By......... x QG�t?.......-----'............................_ ........ ............. ���`u :. — to Application Disapproved for the following reasons---------------•-------••---------------...----------------.......---------------'..................._....... ......................................•-••--'•--•-•-•---..........------..................-------•---•••---•-••••---------'-•--•---•-•----•••......•..........------.....------•--------•-•-•---......� Permit No....... ._._._.. ` �._.. Issued.............../..._..!�!... a-------- Z Fz ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........._0 F......FAA Appliration for Disposal Works Towartution Ilernfit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: LJDT 4- '5Te __- EC ............ Location-Address or Lot No. .................1�4 Z:"t .e. -,(- _. ---—------------ -------------------------------------------------------------------------------------------------- Address ........... ' Owner;��,_-e-—--------:- ----------------------- -------------------------------------------------------------------------------------------------- Installer Address Type of Building 61 Size Lot..........Sh&...Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 04 Other fixtures ....................................�0-7 < �e—------------------------------------------------------------------------------------------------------ W Design Flow.............Un...................gallons per person pgr day. Total daily,flow.............40.62n...............gallons. 94 Septic Tank—Liquid capacitv/5_fl�xallons Length-In.0". Width;! '&... Diameter................ Depth.k.,� Disposal Trench—No. ......._ ..... Width.................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No.......Z.......... Diameter..... ..... Depth below inlet..??.:... ..... Total leaching area.Aa(:-__)...sq. ft. z - Other Distribution box 1( Dosing tank 0-4 ) 7_ ;�=iA117PAX1 Q-1 E) Percolation Test Results Performed by.__..._..............................................Pt.E.......... Date... .............ir................. Test Pit No. I..Zn....minutesperinch Depth of Test Pit.... Depth to ground water JV I 0-� Depth to ground , ACT. 1­4 ".... ...........44 Test Pit No. 2................minutes per inch Depth of Test Pit....*!_'T-'­f...... und wated .. ... 9 1 ,- ................... ...............................................�4.................11,................................... ............... 0 le"T Description of Soil ......I-rW-11 C45...... . ......... .... ........ ........... .....I.C,9j J.e�r�.....t .1........ ...................r 6t� ........�w —.J zf.4 j(_-1......... .. ... %_ 1� ;7 ...................... ............................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees- to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T LZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board,mpf health. 01 ... .. .. .... ............... ..... ................. Da4' Application Approved By........�- i.....�- ........................................... ............ Date Application Disapprbved.for the following reasons:............................................................................................................ . ......................... (......................................................................................................................................t.....................Date.................... I . . —, - Permit No........ ........ .. Issued--...------ ......... ------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. C ....�OF..........�... .. ......­.............Trrtifiratr of Tamphattre THIS IS TO CERTIFY,-That the Individual Sewage Disposal System constructed or Repaired by...................::;............ .------- -&-. ............................................. ................................ Installer F.(. at.......- t... ..........ff.............. ........U_r ............................................................................................. has been installed in accordance with the provisions of Tl 11 12 5 of,The State Sanitar 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. ---- 1 :L!-- ---2----I-----�----r-l-)-/------------------------------------In-s-p e-c-to-r-..-..-..-..-..-..-..-..-...-..-`..�.\.-...\V­ - ..-..-..-..-...-..-..-..-.-.-..-..-..-..-...-..-..-..-..-.. ------ ---------- ------------THE COMMONWEALTH-OF MASSACHUSETTS0 ------ --------- BOARD OF HEALTH /CADO............OF.................... .......nete7.......... FEE Disposal Varks Tanstrurtion frrmit Permission is hereby granted.........Q%'aN�c..r -- -------------- ...................................................................... to Construct or Repair an Individuad Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Construction Permit- -N --o_�.3�35-Dated_._._............ — -------- ........................ DATE..................lj- • ..................... ...........................................Board of Health Fa f S r{'-� ;1. ! '� !�d ��` � �i�•�i� „!'+ram - r �" gyp•, ��� �`.� r --.,.... 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' `�- �14-l'IZ wcsaEo sra•.�E � \ ,, ,- '� \.____• -/;,�� � _¢-��r_=.*��F � ��-ram. \ `) P \ _ Grdl.l.0►.1 TA.tlV- t ti4 / � j Y�TToM v - 1 ITE ol>Jo G..�11�C IFLA K� ---- r aEfii oca Tt� G i v; 'RTE -(eeMOUTu, moss �.t till .'`iC.11� , R.L,s. P E. D,4TV' oNED �a'TE