The URL can be used to link to this page

Home My WebLink About0010 ACORN DRIVE - Health 10 Acorn Drive t West Barnstable A=216-027 ' i Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o: C.: M 10 Acorn Drive (a.k.a. 942 Oak Street) ' Property Address y' Peter G. & Kathryn Hausser Owner Owner's Name ... information is required for every West Barnstable MA 02668 October 21, 2016 '? page. Citylrown 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Flaherty Jr.,RS, REHS use the return key. Name of Inspector Flaherty Environmental Services Company Name P.O. Box 81 Company Address Yarmouth Port MA 02675 Cityfrown State Zip Code 774-994-1166 SI#4713 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ia'tl t October 22, 2016 Inspec or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority,(Board of Health or DEP)within 30 days of completing this inspection. If the system 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.do�-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal S stem-Page 1 of 17 ' r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Acorn Drive Ia.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owners Name information is required for every West Barnstable MA 02668 October 21, 2016 page. 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.6116 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 M 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owners Name information is required for every West Barnstable MA 02668 October 21, 2016 page. Cityrrown 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 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. 8. Kathryn Hausser Owner Owner's Name information is West Barnstable MA 02668 October 21, 2016 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑i The system has a septic tank and soil absorption system (SAS) and the SAS is within 103 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 mere from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 ' r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 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. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5. Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 10 Acorn Drive (a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is West Barnstable MA 02668 October 21, 2016 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage private well 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is West Barnstable MA 02668 October 21, 2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner, not since purchasing property in 2012 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C4M , 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is every West Barnstable required for eve MA 02668 October 21, 2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed 1/8/2003 per BBOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >100 feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight, venting through dwelling adequate, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 8" t5ins.doc-rev.6/16 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 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26 Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? dip stick, tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): maintenance pumping should be performed at this time and every two to three years, inlet&outlet tees in good working order, tank seems structurally sound, liquid level is appropriate, no evidence of leakage 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 10 Acorn Drive (a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. Cityfrown 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 M 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): dbox seems level, no evidence of leakage 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 10 Acorn Drive (a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) ❑ 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) 500 gallon precast leach chambers with stone around & between in a 12.83'W x 311 x 2'D configuration, soils sandy with gravel &cobbles, no signs of breakout or hydraulic failure, vegetation typical (lawn) 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 t5ins.doc-rev.6116 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 10 Acorn Drive (a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is required for every west Barnstable MA 02668 October 21, 2016 page. Cityfrown 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.6116 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 10 Acorn Drive (a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. Cityrrown 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 t5ins.doc•rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is West Barnstable MA 02668 October 21, 2016 required for every page. 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: >20feet 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: USGS maps& Barnstable Hydrogeology maps indicate no groundwater for at least 20' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc.rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 10 Acorn Drive(a.k.a. 942 Oak Street) Property Address Peter G. & Kathryn Hausser Owner Owner's Name information is required for every West Barnstable MA 02668 October 21, 2016 page. Cityrrown 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 Z 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 v i r Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE 1 t,Lvrl LOCATION /7� /� sTlZtt`�T SEWAGE N Oo� .SIcS VILLAGE Lt g,.,jrTTAI� ASSESSOR'S MAP&LOT alb—0::•7 INSTALLER'S NAME&PHONE NO. A46 00*0 SEPTIC TANK CAPACTfY_t<XrsTitt, l SbD ��4/ LEACHING FACILITY:(type)d3 (size) NO.OFBEDROOMS 4' BUILDER OR OWNER l�LF"43�C'TE PERMITDATE: �'1,�3I o COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ref PIAA Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ?e r~ ?IA/J Feet Edge of Wethtnd and Leaching Facility(If any wetlands exist within 300 feet of leaching facility�j t ' Al 16 Feet Furnished by 1 C • � I I'' i r. 61= let- ---I A _'-- _ /TTT A1• 1 Commonwealth of Massachusetts Title 5 Official Inspection Form ^' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ¢Y 10 ACORN S Property Add re s Owner JOHN &SANDRA LALIBERTE information is Owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 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. General Information cn the computer, � use only the tab 1. Inspector: So key to move your cursor-do not MARK L WHITE use the return Name of Inspector key. NEIGHBORHOOD WASTE WATER ,y Company Name 350 RT 28 Company Address WEST YARMOUTH MA 02673 City/Town State Zip Code 508-775-2820 S113381 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: X❑ El ```\ Passes Conditionally Passes o��plt ,l9ss�.,,�� Needs Further.Evaluation by the Local Approving Authority MARK ' o. WHITE *: No.S13381 to JUNE 26, 2012 Insp',e or's Signature Date y - 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 and1copies sent to the buyer, if applicable, and the approving authority. •a;,;„ C�i a ****This ii ort 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pag 04 e of 20 n_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T_ , 4 10 ACORN ST Property Address Owner JOHN & SANDRA LALIBERTE information is Owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 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: ❑x 1 have not found any information which indicates that any of the failure criteria described ,in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 10 ACORN ST Property Address Owner JOHN & SANDRA LALIBERTE information is Owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout 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).- El 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form ' i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments x „ 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 City/Town State Zip Code Date of Inspection 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 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 Cityrrown State Zip Code Date of Inspection 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 ❑ ❑x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 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 El Z than Y2 day flow B. Certification (cont.) Yes No 0 ❑x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: E ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. El M Any portion of a cesspool or privy is within 50 feet of a private water supply well. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name required for every WEST BAR.NSTABLE MA 02668 JUNE 26 2012 page. Cityrrown State Zip Code Date of Inspection ❑ 0 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.] ❑ 0 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 16,000 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. 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? 0 ❑ Has the system received normal flows in the previous two week period? t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,_ E 10 ACORN ST Property Address Owner JOHN & SANDRA LALIBERTE information is Owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 City/Town State Zip Code Date of Inspection ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? ❑X El Were as built plans of the system obtained and examined? (If they were not available note as N/A)N/A ❑X ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑X ❑ Was the site inspected for signs of break out? ❑X ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? 0 ❑ 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: ❑X ❑ Existing information. For example, a plan at the Board of Health. 0 ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 343 D. System Information t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 10 ACORN ST Property Address Owner JOHN & SANDRA LALIBERTE information is Owner's Name ad for every page WEST BARNSTABLE MA 02668 JUNE 26,2012 page. City/Town State Zip Code Date of Inspection Description: SYSTEM CONSISTS OF A 1500 GALLON SEPTIC TANK , A DISTRIBUTION BOX AND 2-500 GALLON DRYWELLS. Number of current residents: 2 Does residence have a garbage grinder? ❑x Yes ❑ No Is laundryon a separate sewage system? If es separate inspection required] M. Yes ❑ p 9 Y [ Y P P q l No Laundry system inspected? ❑ Yes ❑ No Seasonal Use? 0 Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 10 ACORN ST Property Address Owner JOHN & SANDRA LALIBERTE information is Owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 City/Town State Zip Code Date of Inspection Sump pump? ❑x 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 ElNo Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes El No Water meter readings, if available: D. System Information (cont:) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NO RECORD OF PUMPING Was system pumped as part of the inspection? ❑ Yes ❑x No If yes, volume pumped: gallons t5ins•11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form ' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 City/Town State Zip Code Date of Inspection 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): D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 01/08/03 Were sewage odors detected when arriving at the site? ❑ Yes Z. No Building Sewer(locate on site plan): Depth bellow grade: 2 FEET 5 INCHES feet Material of construction: ❑cast iron ❑x 40 PVC ❑ other(explain): t5ins•11t10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 City5own State Zip P Code Date of Inspection Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): RAN CAMERA UP THE MAIN LINE , LINE WAS ALL CLEAR, INLET TEE &OUTLET TEE IN PLACE Septic Tank(locate on site plan): Depth below grade 1 FOOT 6 INCH feet Material of construction: ❑x 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) El Yes El No Dimensions: Sludge depth: 2 INCHES D. System Information (cont.) t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 10 ACORN ST Property Address Owner JOHN & SANDRA LALIBERTE information is Owner's Name required for every WEST BARNSTABLE MA 02668 JUNE 26 2012 page. Cityrrown State Zip Code Date of Inspection Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 16 INCHES Scum thickness 2 INCHES 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? 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.) Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name required for every WEST BARNSTABLE MA 02668 JUNE 26 2012 page. City/Town State Zip Code Date of Inspection Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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.): TANK IS IN GOOD SHAPE, SCUM &SOLIDS ARE AT GOOD LEVELS 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 0 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.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 20 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name requ.red for every WEST BARNSTABLE MA 02668 JUNE 26,2012 page. City/Town State Zip Code Date of Inspection *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert AT INVERT. 1 Comments(note if box is-level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX SHOWS NO SIGNS OF LEAKAGE OR CARRY OVER AND IS STRUCTURALLY SOUND Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 20 I Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L Y 10 ACORN ST Property Address Owner JOHN & SANDRA LALIBERTE iinformation is Owner's Name required for every page. WEST BARNSTABLE - MA 02668 JUNE 26,2012 9 City/Town State Zip Code Date of Inspection 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: D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: 500 GALLON 0 leaching galleries. number:2 DRYWELLS ❑ leaching trenches number, length: ❑ leaching fields number, dimensions` t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name required for every page. WEST BARNSTABLE MA 02668 JUNE 26,2012 Cityrrown State Zip Code Date of Inspection ❑ 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.) BOTH DRYWELLS ARE BASICALLY DRY, A SMALL PUDDLE IN ONE THE OTHER SHOWS NO PUDDLING AT ALL. 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 D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name required for every Pa9e•, WEST BARNSTABLE MA 02668 JUNE 26,2012 Cityrrown State Zip Code, Date of Inspection 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 ACORN ST Property Address Owner JOHN & SANDRA LALIBERTE information is Owner's Name required for every WEST BARNSTABLE MA 02668 JUNE 26,2012 page. Cityrrown 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 ❑x drawing attached separately t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , . . r 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name edforevery page. WEST BARNSTABLE MA 02668 JUNE 26,2012 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope Surface water ❑x Check cellar Shallow wells Estimated depth to high ground water: 15+ feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record If checked, date of design plan reviewed: 7/31/02 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:PER PLAN DATED 7/31/02 t5ins•1 U10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 20 Commonwealth o monwealth of Massachusetts 1 : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F dt 10 ACORN ST Property Address Owner JOHN &SANDRA LALIBERTE information is Owner's Name required for every WEST BARNSTABLE MA 02668 JUNE 26 2012 page. City/Town State Zip Code Date of Inspection Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist x❑ Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑x System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/,d0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 20 of 20 No...... ...... F ............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......I....OF"2�4_7 ................ .... .Z_0C_...................................... Appliration -for Bitipaiial Workii Tutuitrurtion Vanift Application is hereby made for a Permit to Construct or Repair (Z-1-an Individual Sewage Disposal Item at: .... ... .. .......... ........... L-.'c..4i;o--- --- .... ................................... ........................................ �S_s.... .......... ... ....................................... ........... or Lot No. .......................................................... rn eZ2. Owner Address - I- -- -------------------------------------------------- .staller -------------------------------------------------------------------------------------------------- Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder Other—Type of Building ---------------------------- No. of persons..----.-----.-----.......... Showers Cafeteria Otherfixtures ---------------------------------------------------- ........................................................................................ Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity------------gallons Length................ Width....--.......... Diameter----------...... Depth....------.----. x Disposal Trench—No- -------------------- Width--.-------..--.-.--- Total Length----.--.--------.-.- Total leaching area-_-----------------sq. f t. Seepage Pit No--------------------- Diameter--------.----------- Depth below inlet---................. Total leaching area--_-------------sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- ----__--------------------------------------------------------- Date---------------------------------------- Test Pit No. I................minutes per inch Depth of Test Pit.--.._........----.. Depth to ground water...-.--..--------.-----. !� Test Pit No. 2................minutes per inch Depth of Test Pit.--.............---- Depth to ground water-...-.--------------.--. ------------------- ..................................................................................................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------- x ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ --------------------------------- -------------------------------------- ............. U �Latqre of Repairs gr Alterations—Answer when ap licab ------ /Z-1-2-Z--- --- --------I... 7- - - — / - I Y---- ---- - ----------------- --- --------------------- ..... -----40-Z _0...... ... ..... 4------- ... Agregment: 4i The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bgen issued by the boar of health. e I-V 5� � ,f7St g,,,n e ............ ...terL�P- I. ......... i��r---------------- D t Application Approved By. ................................................................................ ------------ 79 -------- ------ Date Application Disapproved for I ze following reasons:---------------------------------------------------------- ..................................................... ....................................................... ------------------------------------------------------------------------------------------------------------------------------------------------- Permit No.. q.1)-V..................................... Issued.............................................Date....... ........... . ..... Date ----------- No......-�U•r •:-.--. ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,r� A ,g .....-- ..OF.. t S.. . '- .-. —............. Appliratiun -fur Di.spuottl Works Towitrurtion Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair (L--y'an Individual Sewage Disposal ystem at• 4 // �-� Loca on•Ass or Lot No. ................................................. '•...................................... --------------- ------...... ........................................................... (/ ( / Owner ........................•----•-•---------•--Address P nstaller Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............:..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4Other fixtures ----- -----------------------------------------------------------•--•-------------------------------------------•----- -------------------------•---- d W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.- WSeptic Tank—Liquid capacity------------gallons Length---------------- Width-.----._..__-- Diameter................ Depth.____._-_--- x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area-----...------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY-------------------------------------------------------------------------- Date--------------------------------------.. Test Pit No. 1----------------minutes per inch Depth of "Kest Pit-------------------- Depth to ground water.------.--------- ....... G4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--.-------_----.-___. P4 -•------------••---------.................................................................................................................................... ODescription of Soil.............................................................................................. ------------------------------------------------------------------------- x U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W ----------- U Nature of Repairs or Alterations—Answer when applicabl ...._/ ........... . f r -------------------------- Agre ment: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the boar of health. r,-- Signed:: '- r � /�� g -----•------•---•----•-- ...--••�-_...-- .6.. -� D to Application Approved By----- - ---�C----:- - �---7 _--- ----•-•-•--•----.--•-•------------------------------------------------- Date Application Disapproved for t ae following reasons----------------------------------------------------------------------------------------------------------------- ---•--•-----------------•--------•--------•----------- --------------------------------•---------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date `S THE COMMONWEALTH OF MASSACHUSETTS �lam`is/v y� SO/L _ L=J1�/yir,A T/• �� BOARD OF HEALTH � ....../..� / 'emu v!r l 1 :.................0F..... . �- ., >:{.. .. . A (:�Prrtifiratr of Tompliaurr THIS IS TO rERTIFY, That the. Individual Sewage Disposal System constructed ( ) or Repaired (4--j— C N ! I / Ins Iler tie ------ = ----- .:.............•-------------------------••----•--------•------------•----------- has been installed in accordance with rovisions of Article XI of The State Sanitary C de as described in the ��J 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--•----------.- 77�. --- .. Inspector.----C....L ........................... THE COMMONWEALTH OF MASSACHUSETTS -- BOARDS OFt HEALTH ,0q .... O F.... r--C ...----- . .. ��/Z�Yt�C............................... ...... �� No......................... FEE.---- Di-sVuottl orkp Tonitrurtion Vrrmit ` - Permission is hereby granted---------�•-`"�------._.---•------------•---- ----••-----------------------•----------......---------.......----------••-----..._._ to Construct ( ) or Repair,.,,(4-�_an Individual Sewage Disposal System at ----- _ C� �t.�. SCiV--1 IF ....................:............------. --- -------------- ----------------------------------------------------------------- Street as shown on the application for Disposal Works Construction Permit N0....... ------ Dated------ . . E_.�^?�_....... ------------------------------------- B --d - H -- ----G--/- 9t� oar o -------------------------•------------ ----------------- wokDATE 31ea ,� A T S FORM 1255 HOBBS & WARREN.. INC.. PUBLISHERS/j/f/mt �(J ��•.>1l9GGl�T/r-' /� ��GG/�% �y v 10.00 ;t. *'THE COMMONWEALTH OF MASSACHUSETTS O's��' BOAR® OF HEALTH o�;r ................Town.......---.....OF........----......Barnstable CA l 4JU, Avvlation for Disposal Works Tonstrurtin n .rrntat Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: .•-•9L?. Oak.St;A..West Barnstable .MA 02668 Location-Address or Lot No. B ouglas_Ju-------------•------•-•-------.................---•--------••--•-•--- 9.L1MA 2..9ak..St. ..We t-.Barnstable-, - -02668.... Owner Address a A... __B:_Cesspool_-Service.............................. ......... j28__Bshos__Terrace,___Hyannis,__MA____02601 Installer Address 'a Type of Building Size Lot------ -------- .-.Sq. feet aDwelling—No. of Bedrooms...........3...............................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............3............. Showers ( ) — Cafeteria ( ) Q' Other fixtures ..---•--•---------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter------_-_.__.-. Depth................ x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •---•-••--••-•-•••••••••••••-••---•-...•--••--•-•-•-•-•---------------•-•-•••--....-------------•---.......---••-.......------•----•••.....................•. 0 Description of Soil..Sand-----------------------------------------------------•- V ............................................................... .........--•-----•••••-•--------••••••-•----••---•----•-•-•-•-•-•-•-•••--•-•-•-•----••................................................. UW ••-•••-•---•----------------•------•----••••-••••••------------------------------------•--------------------------------------------------------------------•-------•-------------------------------•-- Nature of Repairs or Alterations—Answer when a plicable.100!ugallon: pre-cast septic tank, D-box, and 1-1,000 gallon leach pitoverflow. • ••••••••••--•---••-•-•••••-••---••-••.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT E 5 of the State.Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complia s been issued by the b1 of th. Application Approved BY •. • �A�83..................7 - Date Application Disapproved for the following reasons:-----•------•-•--•----------------------------------------------------------•----------.._.........---...------ ----••---••••--•••-••-••-•-•-•••--•----•--••-•••....••••-•-•..................•••••......-•--•...-••-------••-••-•--•••---•......-•-•--••••••••...•.................................................... Permit No.._83.-............... ._.. Issued 7/11/83-....... .Date Date -... Z .. ; �. Fims.4...10,00...... 'THE COMMONWEALTH OF MASSACHUSETTS M BOARD OF HEALTH ------ &0141..............0 F fa Is able Appliration for Disposal Works Tnnitrnrtinn ramit Application'is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: .....942..Oak--Si`.,..�sl�st.Easns�2:t�la, ;tIA....026F.8 .................................................................................................. Location-Address or Lot No. .................. .... J42..Oak... t..,..1Teat..Rantahle.,.. $....t1266Pa..... Owner Address a .___.........E.Cesspool..Sery ce........................................ 1,2f'.:.pi,9bLaps.Te=ace,....iyannis-,.J4A....A2fit11..--- Installer Address � Type of Building Size Lot............................S q. feet ,. , Dwelling—No. of Bedrooms..........3...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons...........3.............. Showers — Cafeteria QI Other fixtures ------------------------------- . W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter------------_... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.....................Total,leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................... ..................................................... Date........................................ � Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------................. RI' =---•-----------------------------••----------------------------•--..........-•--•-•---•-------............-•-•---•---------------------------._.._..__....-- ODescription of Soil_San�L--•------••------------•-•-••--------------------------•--------------•---------------------------------------------------------------•-•••---------------•- x U -•---------------•-----------------------------------------•--......•--------------...........-------•--------------------•-•---•••------•----.....-•--•-•••••--••-••---------------•-----------•.....•. W ----•--•------------ -•------------------------•--------------•----••------•---._._._......-•••••••---•-------•••---•------------------------------------------------................................. UNature of Repairs or Alterations—An wer when plicable.15006ga11Qn-,---pre--caat... ent p...t.an .__�-bQx, and 1-1,000 gallon leach- pit (overf'lai). • . ...................•-------------------•••--•-----•-•••----•-•-•••----•----•------------•-----..._.._.....----- Agreement: The undersigned 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 Complia e s beeA issued by the bo d It Signd-...............--•..............----- Application Approved B ;-- , ` -----------••••7� tiV9- ....... Date Application Disapproved for the following reasons------------------------------•--•---•-------------...------------------------------------------------------••--- .........................................-............................................................................................................................................................... Date PermitNo.-�3----------------------------------•-----------•--. Issued------7/11�A3--•--•--------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH Iarn......OF....... `arnstable ....................................................... TrrtifirFatr of Toutph anrr ,THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X ) by A.&_B..Cesspool Service.....128 Bishop�.Terrace,..Iiy il>� i��l.....02601........................................ - nstaller at.942 Oak St.. West Barnstable, '�A 0?66 S "-DQ�1 g!s JAk...-------•-._...•--.......-•--------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the ag�lication for Disposal Works Construction Permit No.0- ..................... dated_--..7/1 _83.__._...__......_.__..___. THOSSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE 'AS A GUARANTEE THAT THE SYSTEM *ILL FUNCTION SATISFACTORY. DATE 7��.,/� 3 Inspector. ---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH- Town Barnstable bS ...........................................OF..................................................................................... 10.00 No............ ..��'.... FEE ..................... Etfipnpa l Works Tonstrnrtion rrntit A & B Cesspool Service Permissionis hereby granted..................................-........................................................................................................... to _Qonstruct ( ) or Repair � ) an Individual Sevlra a Disposal System at Oak t.l T,Jest Larnstable,.._DA.....OW -Douglas Ju Street as shown on the application for Disposal Works Construction Permit No.._Q-.......... Dated....741M...................... Qoar r d---of-------------------------------------------------•- Health DATE............7/7//X.......-/------��-----------•-----------------•-----•---• FORM 1255 A. M. SULKIN, INC._BOSTON \