Loading...
HomeMy WebLinkAbout0054 CARLSON LANE - Health Carlsom Lane A hans table: A= 133-063 r I TOWN OF BARNSTABLE LOCATION CfLci SJ'% L01C SEWAGE VILLAGE V, I>♦orh btt ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. N 31- fS G a' SEPTIC TANK CAPACITY I, Ja V LEACHING FACILITY.(type) (10 (size) NO.OF BEDROOMS 3 OWNER D q W rt ti� PERMIT DATE: 1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells'exist on site or within 200 feet of leaching`facility) Feet Edge of Wetland and Leaching Facility(If an etlands exist within ,^ 300 feet of leaching facility) /y A Feet FURNISHED BY 1wr3.'1 NA � a � 41 9 31.3 t Ith a - c c ' / TOWN OF BARNSTABLE LOCATION �� a0lrISQYN Ln SEW96E#_-Q,5d� VILLAGE ASSESSOR'S MAP&PARCEL S NAME&PHONE NO. _ -� SEPTIC TANK CAPACITY 1000 LEACHING FACILITY.(type) i (size) (0g0 NO.OF BEDROOMS J OWNER t�Sd i'1 PERMIT DATE: C DATE'.To5P �'� I`� 10 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 8 �. £� ' ,fix i r •Vie:. • 4 4 4 1 •• ! ! ! f I f ! f / / f / f / f f F r ... L \ \ h L h h L L h \ h h h h \ \ L 4 h L k L 1 h L \ k \ L L 4 \ ♦ 1 h ♦ h - ♦ ♦ \ \ \ \ L ♦ L \ L'♦ ♦ \ 4 4 ♦ 4 4 h 4 'L h L L L ♦ h L h L h L L 4 L h L L h L L L 4 4 4 h \ 1 4 4 4 \ h h h • h L h L 4 h h \ ♦ 4 ♦ L 4 L 4 \ 4 \ \ ♦ 4 4 4 \ h 4 1 1 4 \ h ♦ ♦ ♦ \ ♦ h ♦ ♦ L \ 4 h \ 1 f / ! f J 13 4 4 4 h ♦.\ 4 4 ♦ \ h L h 4 4 4 4 '� 1 4 4 4 4 L 4 4 \ r r ! f i i f / / / 4 4 \ 4 L.h 4 h h 4 ♦ 4 h 4 h 4 4 h 4 \ h 4 L \ 4 L \ \ L L h 4 L ' h h h \ ♦ ♦ \ ♦ ♦ ♦ ♦ \ ♦ h L 4 k 4 4 L h k 4 \ 4 \ \ \ ♦ 1 L 4 L \ \ \ h 4 \ 4 4 \ 4 4 1 h 4 ♦ h h 4 4 ♦ L L \ \ \ 4 L L \ 46 \ \ L 4 ♦.L.♦ \ ♦ L \ 4 4 4 4 \ \ 4 ♦ ♦ \ \ ♦ 4 \ 4 4 \ h 4 \ \ h \ \ ♦ h L 4 h 4 \ \ h h h 4 4 \ \ h 4 L h L L 4 L h 4 h 49 � . .....a f No.. Fee TH COMMONWEALTH OF MASSACHUSETTS Entered in co uteri Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21ppficatiou for bisposar *pstetu COustructiou Permit Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.� co"Y�%�'1 l Ck Owner's Name,Address,and Tel.No.,D V- Assessor's Map/Parcel aw �� pRYC4.. (3 -*Y\ S C C Installer's Name,Address,and el.No.1-l�_�?�—C'A S1 Designer's Name,Address,and Tel.No.—I— �� V C �U .►'1 SQI .Y?�� " C L- ��'1 S I Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ZS,l 61Y% No.of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow(min.required)���x�s'�30 gpd Design flow provided q �1 gpd Plan Date �, ,�+ Number of sheets Revision Date Title S-S ��G� (� h �° 1����'Vll('.; . i�q 7�V CAY 0) Q 4M M_SAAtwh%r�4Jk. Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued is Bo of Health. gn d m Date 11 1 Application Approved by '' Date `ll Application Disapproved by Date for the following reasons Permit No. Date Issued % No., `3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co uter: A\• PUBLIC,HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rp'lication for Disposal OpBtrut Construction 3perm t Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.5,y C&Y VS o r'1 .l a}^rQ1 Owner's Name,Address,and Tel.No.`ao`�_ ���•—c� �(j 1j Assessor's Map/ParcelmcwD �j2j 9ali cs �� �rn c1 J �C 2 �r\� 1"S1cat-\ � ��}�JU Installer's Name,Address,and Tel.No.—I1�_ �_4 L{ ` Designer's Name,Address,and Tel.No.`s-J�} b °D 1�_: ,, ccn" C_�\nc� 1�c. .v1 SG.CY�.a s \C 1^ YY\�a 'A 5 Type of Building: , 1 Dwelling No.of Bedrooms ��pp Lot Size sq.ft. Garbage Grinder( ) Other Type of Building�Q C 1 CJ kY-\C No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided ?S gpd Plan Date " +�� (U Number of sheets Revision Date .` A . Title C\�L-e� 0(A ;> t) 1')� -n C�, C J�CVV\jC 9N ( ()\Y 1 C jy) o\hi INgC &Am's,c�`��P Size of Septic Tank (� r Type of S.A.S. tl Description of Soil ` J Qu �(� - ) Nature of Repairs or Alterations(Answer when applicable) s Date last inspected: Agreement: i' ^- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i accordance with the provisions of Title 5 of the Endironmental Code and not to place the system'in'operation until a Certificate of Compliance has been issued is Bo4rA of Health. b'gn d-.. % L Q'� 1 Date Application Approved by Date Application Disapproved by Date for the following reasons i Permit No. Date Issued ------------.-------------------------------------------------- ------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE MASSACHUSETTS Certificate of Compliance THIS IS TO CERTJIFY,t at t Thi e S wage Dis osal syst C tructed( ) Repaired O UpgradedAbandoned )by Y 1/ at has been cons c ed in acIffiecd e with the provisions of Title 5 and the for Disposal System Construction Permit NoL� Installer Designer t #bedrooms Approved design ow I gpd The issuance of this permit t jejrkslrueas a guarantee that the system will fu o as igti4ed. Date J/ Inspector ------- - - ------------------ ------------------------------------------------- ------------------- - — No. nS Fee HE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal Ops tlY Construction Permit Permission is hereby grat�Led t CM,�_ ) Repair,( Upg�ra�de S ) �bbandoSystem located at �f L/i s # i ) ✓ . j� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio us a co pleted within three years of the date of this permit. Date Approved by i Town"of Barnstable °Ft"E ram, Regulatory Services Thomas F. Geller,Director BARN ' STABLE MASS. Public Health Division 1639. 9 nss. g Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: I �ql Sewage Permit# Assessor's Map\Parcel MOL ( PQrC%� 0&S Designer: Qa�/LA O n Installer: Address: Address: \S S'�2 - W0,0 -4avwicl%; MBA 0�� 5 avw► C�n M LAS On 1 �_ O&r) 59eOLK'CAn was issued a permit to install a (date) , i (installer) septic system at 5J`t C-G`\-�S dY) �i'` Si`& " I"I %ased on a design drawn by (address) ` I �)GXV-L cxS-6-n dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan.revision or certified as built by designer to follow. OF MgSsC' DAVID 9 "Jnstr's Sign e)2 MASON o No.1066 r , yea � �41TARV� (Designer's Signature) (Affix Desi r s-Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc ` Town oftBarnstable P# Department of Regulatory Services . tr,sr Rta 's Public Health Division Date AIPAO MAM P 200 Main Street,Hyan is MA 0260 Date Scheduled // Tlme Fee Pd. Soil Suitability y %nv ��/1.��Assssment for Sewa l Performed B Witnessed By: � f i LOCATION&GENERAL INFORMATION Location Address Owner's Namer 6,4t Sy C av 15�►1 l,,or`+t,y,►c S�- w ri 9 lk- Q o o>natd ajgr�'15� b�]�' t-AA Address�3�5�c�v,d/�Wv`e,Lo n9 Sl a� IMrG U�1v5 0 Assessor's Map/Parcel:t 33/a(-3 Engineer's Name NEW CONSTRUCTION REPAIR Telephone Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes) C3 ZEZ 10 c f t ' :low Ls M Parent mmatEYfal(geologic) Depth to Bedrock v Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater ' DETERMINATION FOR SEASONAL HIGHVATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date Time Observation Hole# I Time at 9" Depth of Pere �i Time at 6" Start Pre-soak Time @ I Time(9"-6") End Pre-soak ` Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC r DEEP OBSERVATION-HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel 11 i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG- Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG ) Hole# n * Depth from Soil Horizon Soil Texture Soil Color Soil Other '\ `v Surface(in..) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. w Consistency.%Gravel) I 0 Flood Insurance Rate Man: O _O11 Above 500 year Flood boundary No J�es Within 500 year boundary No Y Y/ es `v Within 100 year Flood boundary No 1_//Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious rpat fiat exist in all areas observed throughout the area proposed for the soil absorption system? —a�I.r—� If not,what is the depth of naturally occurring pervious material? Certification I certify that on © (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was perfo ed by me consistent with the required training,expertis d ex en described in 310 CMR 15.OI7. S igna Date O�L Q:\SEPTIC\PERCFORM.DOC 4't Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal'System Form-Not for Voluntary Assessments w 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections ay Company Name PO Box 896 Company Address East Dennis MA 92641 -A City/Town State d4ip Code r-. 508-385-7608 S13742 £ n Telephone Number License Number f r1Q . B. Certification I certify that I have personally inspected the sewage disposal system at this address and thatlthe information reported below is true,accurate and complete as of the time of the inspection.Theinspectton 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 06/09/12 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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and underthe 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. 12-2- 11-2) t5ins•11110 Tdie 5 Ofrrc' n e 'on Form:Subsurface Sewage Disposal System Page 1 of 17 L_ Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every west Barnstable MA 02668 06108/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont) Inspection Summary:Check A,B,C,D or E/ahaays complete all of Section D A) '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: B) System Conditionally Passes: l ❑ 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","non 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 exilation 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 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 page. Cityfrown State Zip Code Date of inspection B. Certification (cont.) 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 wins al VIQ iiu8 5 oft' a.;lnspewor.Foiiml sut U1lace seeirage u4M!s,a'stemini c Page'.of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 page. CityRown 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: c _ 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 El ® Liquid depth in cesspool is less than 6"below invert or available volume is less , than /�day flow t51ns-11/10 TRIe 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 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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 GMR 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 11 of a public water supply well If you have answered"yes"to any question in Section:E.the system is considered a significant threat, or answered"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-11/10 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 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Flame information is required for every West Barnstable MA 02668 06/08/12 i 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 ® El 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 (f 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•11/10 Title 50ffcial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 • e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑;' Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑. Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: t5ins•11/10 Title 5Official inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 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: 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 page. Cityrrown State Zip Code Date of'Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 07/31/80 per BOH Were sewage odors detected when arriving at the site? ❑ Yes. 0 No (Building Sewer(locate on site plan): Depth below grade: 2.5 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: 1.7 feet Material of construction: ® concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal,fist age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,000 gal Sludge depth: 3" t5ins-11110 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 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is West Barnstable MA 02668 06/08/12 required for every page. CityiTown State Zip Code Date of inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 2" Distance from top of scum to top of outlet tee or.baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle t 6" 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.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal El fiberglass E 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•11/10 Title 5 Official Inspechon Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Mal Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments g 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 page. Cityfrown Stage 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•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12: page. Cityrrown 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 even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order., ❑i Yes ❑ No Alarms in working order: ❑ Yes ❑ No 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: t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page U of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54'Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 page. CityTTown State Zip Code Date of inspection D. System Information (cont.) Type: ® leaching pits number: 1. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has a 6'x6'precast pit surrounded two feet of stone.There was 15"between the inlet invert and the liquid. 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•11i10 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 i r Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 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•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massaetiuseft Title 6 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owners Name information is reqtAred for every West Barnstable MA 02668 06/08/12 page_ City/Town State Zip Code Date of irspection ®o System Wbr ion (cunt.) j Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to I at least two permanent reference landmarks or benchmarks.Locate a#wells vift►in 100 feet.Locate where public water supply enters the building.Check one of the boxes belovr_ j ® hand-sketch in the area below ❑ drawing attached separately i i (8 i lZQ s �a t5h"•11110 Tft 5 omaw inwcom Form:wwunce a-me 04-w sy-6-•P"s 16 of V N Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 54 Carlson Lane Property Address Cassidy Fougere Owner Owners Name information is required for every West Barnstable MA 02668 06/08/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record I 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 show an elevation of over 20.0 feet Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Carlson Lane Property Address Cassidy Fougere Owner Owner's Name information is required for every West Barnstable MA 02668 06/08/12 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 ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal.System either drawn on page t5 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. —/ © Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes RpPrication for Oi5pog;al *pgtem Con.5truction Permit Application for a Permit to Construct O Repair O Upgrade O Abandon O ❑Complete System 1?I Individual Components Location Address or Lot No. 54 Carlson LAME Owner's Name,Address,and Tel.No. W. 19cLrns+abke Tf:Flnywll,SoN Assessor's Map/Parcel 33—06-3 54 LAeLSON LN W•BA"5TA1h;E I� t staller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ObeeT Cl I LFOy - Bt13 r-YUAVAT10t4 VIA Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S' ned Date 31-L3 10 Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued -------------------------._ ENO. �/ Q v, Fee l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pprication for Misspool 6P.5tem Conotructiou Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 5 L' CCU r 16p{1 L0 VE Owner's Name,Address,and Tel.No. W T3nr ti iStabl e Tur I y W ILS0(14 Assessor's Map/Parcel �3�-d(o3 5 til C f1 15 nl t N W f3Ai?AJ!5I A 3 L:E Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. u�eeT L-rILF0 1 Y, A14ATiu{,I (A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures F Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) I Date last inspected: Agreement: The undersigned agrees.to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed .� `j Date 3 1 Z 0 '] Application Approved b�_ \ Date Application Disapproved by' Date for the following'reasons t Permit No. —xv Date Issued —————————————— ——————— ——————_———'———————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired. ( ) Upgraded Abandoned( .)by at �` C C t �(; ' n k l P- j�N . (1[{��, �� h has been constructed in accordance J with the provisions of Title 5 and the for Disposal System Construction Permit No. `7 dated Installer (I I Lyl yp -( Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wi 1 Tune ton as designed. < <. Date J Inspector•.._{-,1.ri ,, } _,.. No...: / i � ' - . Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lwigogal *P!gtem Con.5truction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at 5 H C C1 r`!s(i r \ �CA I l P W �C 1 Cat h \ f and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction m��jstbe completed within three years of the d e of Date 4�/� Approve by ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments „a 54 Carlson Lane Property Address ,Jeffrey Wilson Owner Owner's Name information is West Barnstable MA 02668 April 19, 2010 required for P every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: �- A. General Information r When filling out _ forms on the computer,use only the tab key 1. Inspector: to move your �ca = Patrick M. O'Connell cursor-do not Name of Inspector ¢ +� -a use the return key. Septic Inspection Services Co. - Company Name h `�:=� Q 189 Cammett Road Company Address Marstons Mills MA 02648 refs" Cityrrown State Zip Code 508-428-1779 SI 12855 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 12— ,X,,- r)�'� April 19, 2010 I pector's Signatu a Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10 000 gpd or greater, the inspector and the system owner shall submit the ,report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 10-98 Wllson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 011 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is required for West Barnstable MA 02668 April 19 2010 _ every page. City/town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Tank is not in need of pumping at this time, leaching pit had 17-14"of effective leaching. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 10-98 wilson.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane _ Property Address Jeffrey Wilson Owner Owner's Name information is required for West Barnstable MA 02668 April 19, 2010 every page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 10-98 Wilson.cloc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is West Barnstable MA 02668 Aril 19, 2010 required for p every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 10-98 Wilson.cloc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts EKEME�t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is required for West Barnstable MA 02668 April 19, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 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. 10-98 Wilson.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is April West Barnstable _MA 02668 A 19 2010 required for p � , every page. Citylrown 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)] 10-98 Wilson.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 6 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is West Barnstable MA 02668 April 19, 2010 required for p every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A Well Water 9 ( y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 10-98 Wilson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is West Barnstable MA 02668 April 19 2010 required for p every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None 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): Approximate age of all components, date installed (if known) and source of information: 'Compliance date 7/31/80 Were sewage odors detected when arriving at the site? ❑ Yes ® No 10-98 Wiilson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is West Barnstable MA 02668 April 19, 2010 required for P every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' 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: 14 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Trace Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured 10-98 Wilson.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth nwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is West Barnstable MA 02668 Aril 19, 2010 required for _ p every 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.): Tank is not in need of pumping at this time, tees were intact and clear. Liquid level was found at bottom of outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 10.98 Wilson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is West Barnstable MA 02668 Aril 19, 2010 required for _ p every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): No solids or high stains present. Liquid level was found at bottom of single outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-98 Wilson.doc•08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane 'Property Address Jeffrey Wilson Owner Owner's Name information is required for West Barnstable MA 02668 April 19, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ 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.): Liquid level in leaching pit was one foot below inlet pipe with no high stains or evidence of surcharge. 10-98 Wilson.doe-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 L f Commonwealth of Massachusetts . 'Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is west Barnstable MA 02668 April 19, 2010 required for p every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 10-98 Wilson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson - Owner Owner's Name information is West Barnstable MA 02668 April 19, 2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Well 177' from SAS 8 ,, 3 5.4 .... .. ... ... . ... ....... 46 49 Driveway Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Carlson Lane Property Address Jeffrey Wilson Owner Owner's Name information is West Barnstable MA 02668 Aril 19, 2010 required for _ P 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 ground water: 30+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: Low areas of abutting properties are considerably lower than SAS. 10-98 Wilson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 Town of Barnstable FfHE Regulatory Services f snxxsrnste Thomas F. Geiler, Director nn�� MSS. A.Oi Public Health Division v t D MA Thomas McKean,Director , 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 28, 2007 Mr. Jeffrey Wilson P O Box 126 West Barnstable, MA 02668 The septic system located at 54 Carlson, West Barnstable, MA was last inspected on March 151h,2007, by Patrick O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 ( 310 CMR 15.00) due to the following: Leaching pit has 16-18" of effective leaching, outlet baffle in septic tank is missing. Liquid level is currently 2' below inlet pipe with a high stain line 6" above current level. You have 60 days from the date to bring the system to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH D PARTMENT THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by. ataclou niW O =t4 at 15 CC r16nr) anP -Aejrr)e,.I..0 6,1.E .__. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '-=��� ? dated :�/A 1112 Installer r- t Designer #bedrooms Approved n flow gpd The issuance of this permit shall not be o strrued as a_uarantee that the syst will fuatias de 'gned. Date Inspector p IYI/:IfYI t C) , ru I• • • • • ._. • •, m Ir Postage $ . 60 O O Certified Fee �1 p aS aostmark U O Retum Receipt Fee Here (0 (Endorsement Required) ./ M C3 Res L%d Delivery Fee Q J —0 (Endorsement Required) � ra Total Postage&Fees Is Ln O Sent YO, '' 11 N or PO Box No. city re,zr ------------------ s� Certified Mail Provides:o A mailing receipt (asuanab)zoozeun r'oo?8,w,0J Sd o A unique identifier for your mailpiece C A record of delivery kept by the Postal Service for two years Important Reminders: e Certified Mail may ONLY be combined with First-Class Maile or Priority Mail& a Certified Mail Is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. c For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery" a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix labelmith postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. Town of Barnstable GF tME 1p� • ya• ti� Regulatory Services sAAs Thomas F. Geiler,Director 9`bpMASS 639' ���p Public Health Division lFO MA'S� Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax:.,508-790-6304 May 28, 2007 Mr. Jeffrey Wilson P O Box 126 West Barnstable, MA 02668 The septic system located at 54.Carlson, West Barnstable,MA was last inspected on March 15th, 2007, by Patrick O'Connell, a certified septic inspector for the State of ____Massachusetts The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 ( 310 CMR 15.00) due to the following: Leaching pit has 16-18" of effective leaching,outlet baffle in septic tank is missing. Liquid level is currently 2' below inlet pipe with a high stain line 6" above current level. You have 60 days from the date to bring the system to bring the system into compliance.. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH D PARTMENT omas A. McKean,R.S., C.H.O. Agent of the Board of Health � r COMMONWEALTH OF MASSACHUSETTS 4 F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t 5�0 o�3 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 54 Carlson Lane West Barnstable MA 02668 Owner's Name: Jeffrey Wilson - a Owner's Address: PO Box 126 West Barnstable MA 02668 Date of Inspection: March 15,2007 Job#07-53 r+ Name of Inspector: PATRICK M.O'CONNELL ON Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address:. 189 CAMMETT ROAD —ir u� MARSTONS MILLS MA 02648 ap Telephone Number: 508-428-1779 a co CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes _X_ Conditionally Passes Needs Further Evalu ion by the Local Ap o ing Authority Inspector's Signature: % — Date: 3/15/07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching pit has 16-18"of effective leaching,outlet baffle in septic tank is missing. ****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. • Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 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: XX _XX_ 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. Outlet baffle in septic tank is missing,needs to be replaced with a PVC tee. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: r Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _ _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period ? _ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection`? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling:inspected for signs of sewage back up _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] I ; ` Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): N/A Well Water Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/IN DUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped three years ago. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed (if known)and source of information: Compliance date: 7/31/80 Were sewage odors detected when arriving at the site(yes or no): No ` Page 7 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: V Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" Material of construction:_X_concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2' wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 1" 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: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Liquid level is at bottom of outlet invert,outlet baffle is missine. GREASE TRAP: No (locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): f Page S of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): No hieh stains,trace of solids carryover. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits, number: One 6x6 pit. 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.): Liquid level is currently 2' below inlet pipe with a high stain line 6"above current level. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): r- Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Well 177' from SAS • 8 3 ' ........... ........ ......... ....... ........... ............ ....................... .......... ...... ........... ." ........ ... ......... ....... ..... 46 49 Driveway • ., Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Carlson Lane,West Barnstable Owner: Jeffrey Wilson Date of Inspection: March 15,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Please indicate(check)all methods used to determine the high ground water elevation: _Obtained from system design plans on record- If checked,date of design plan reviewed: _X_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: Property is located on hill considerably higher than any known groundwater in area. TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER s . PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by ' 4o . P' O TOWN pF BARNSTABLE t-,LOCATION y (,,ox�5o q C C�r�n _ SEWAGE VILLAGE_ t� � ASSESSOR'S MAP&PARCEL /3 3 Q 6 l`NmS9m==S NAME&PHONE NO. SEPTIC TANK CAPACITY GCSO LEACHING FACILITY.(type)' -,'fi �h (size) 10W Q NO.OF BEDROOMS 3 OWNER 13eSg-�'n� W 1, - P.ERMIT DATE: QC DATE: S Separation Distance Between the: e� Maximum Adjusted Groundwater Ta;;te�to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet '� FURNISHED BY 3 4 f ><<�'�#i'�??>%>����`'?`•.`:i?„i?i?sSi ........ .. ... 46 7 40 3 a i r t DATE: 6/9/99 PROPERTY ADDRESS: ------=------------------ 54 Carlson Lane ---------------------- West Barnstable ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1000 gallon septic tank 2. 1-1000 gallon leaching pit 3. 1-Distribution box Based on my Inspection, I certify the following conditions: 4. This is a title five septic system. ( 78 Code ) 51. The septic system is in proper working order at the present time . SIGNATURE: Name:—,L . Macomber _,Try_—__-- Company: Jose.ph_P. Maco.mber_& Son , Inc . Address: Box 66 -------------------- Centerville , Ma.-02632-0066 Phone: 508-775=3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY Joe JOSEPH P. MACOMBER & SON, INC. �1141 Tanks-Cesspools-Leachflelds '�� 6•� � Pumped & Installed ; Town Sewer Connectlons '9 P.O. Box 66 Centerville, MA 02632-0066 00, EAR 99 775-3338 775-6412 COMMONWEALTH OF MA.SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY Cox S,cret.a ARGEO PAUL CELLUCCI DAVID B. STRU? Governor Co�:ss:ou SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION Proporty Address:54 Carlson Lane Namo of owns. Ann Burchill West Barnstable Address of own • Data of Inspecti es er on: Narrsa of Inspector:(A6aVAA Joseph P. Macomber Jr. I am a DEP approved system Inspector pursuant to Section 15.340 of Tile 5(310 CMR 15.000) Company Nam.: Joseph P. Macomber & Son, Inc. M&T1rg Address: Box 66.. Cpntprvillp, Ma - 02632-0066 T ele04rw Nurnber: 5 0 8-7 7 5-1 R 3 A CERTIFICATION STATEMENT and he he Information reported below is true. accurate have personally Inspected the sew• a disposal system at this address t t t p I certify that 1 p Y P g P Y and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on•sitesewage disposal systems. The system: et 7 Passes Conditionally Passes Needs Further E alustion By the Local Approving Authority Fails / Q inspector's Signature: r Data: (o_ The System Inspect shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department oKnvironmental Protection. The original should be sent tours system owns(•and copies sent to tha buyer. If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of 11 `� PruNeE on stscyc4d V.p.r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTiRCAT)ON (continued) PropertyAddf—:54 Carlson Lane, West Barnstable Owner: Ann Burchill Data of Inspection: 6/9/9 9 INSPECTION SUMMARY: Check A, B, C, o/ D: ill A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 1.6,303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDMONALLY 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. i Indicate yes,•no, or not determined(Y, N,or ND). Describe basis of determination in all Instances. If "not determined', explain why not. The septic tank Is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was installed within twenty(20)years prior to the date of the Inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is Imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken, sett'ed or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken plpe(s)are replaced obstruction Is removed distribution box is levelled or replaced The system required pumpbtg-more than-four-times s yeardue to broken or obstructed pipe(s). The system wAt-pasr Inspection if(with approval of the Board of Health): - broken plpe(s)are replaced obstruction Is removed j revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirxwd) ProP6MAddraa.s: 54 Carlson Lane, West Barnstable 0wri&' Ann Burcbill Dau at kupe d— 6/9/9 9 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 falling to protect the public health, safety end the environment. 1) SYSTBA WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WfTH 310 CI.tR 16.303(1)(b) THAT THE SYS IS NOT FUNCTIONING IN A MANNER WHIWY91LLPR0.g.C(THE PUBUC UEALTI"ND SAFETY AND THE Ds aa0N1 LC ' Cesspool or privy Is within 60 feet of surface water Cesspool or privy Is wlWn 60 fast of a bordering vegetated wetland or a salt marsh. D 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC IF ANY)WATER SUPPLIER, ) ETERJ.tfNE.S THAT THE SYSTO FUNCTIONING IN A MANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIRONMENT: / The system has a septic tank and loll►bsorptlon system(SAS) and the SAS Is wltNn 100 fast of a surface water supply trlbutary to a surface water supply. The system has a septic tank and soli absorption system and the SAS Is wlWn a Zone I of a public water supply weU. The system has a septic tank and soil absorption system and the SAS Is wlWn 60 fast of a private water supply weu. The system has a septic tank and soil absorption system and the SAS Is less than 100 fast but 60 feet or more from a private water supply wall,unless a well water analysis for coflform bacteria and volatile organic compounds indicates tha will es free from pollution from that facility and the pre encs of immonla nitrogen and nitrate n)vogen is aQuai to or let, than 6 ppm. Method used to detstrrJns distance > > (approximation not valid).- 3) OTHER 712P AO revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i CERTIFICATION (continued) PropeM Addrass: 54 Carlson Lane, West Barnstable Owrw: Ann Burchill Dots of Inspection: 6/9/9 9 D. SYSTEM FAILS: You must indicate either "Yes" or "No' to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination Is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No , Backup of•"Wage into iecility"or•vTsterrtcomponertt•due%to an overloaded orc(egged-SAS•or•casspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ZStatic liquid level in thp istnb/Lion box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in essep�l is le f�_ ss than 6" below invert or available volume Is less than 1/2 day flow. f� 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 60 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. If the wall has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems In addition to the criteria above: A2d The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No ' .�+/•�J�,Q the system is within 400 feet of a surface drinking water supply /mod the system•is-within 200 teat ol-a tributary to curlaoa drinking w�ten 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Inforpation. revised 9/2/98 Page 4ofII r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropenyAddrass: 54 Carlson Lane, West Barnstable Owner: Date of Inspection: Ann Burc 1i l l 6/9/99 Check If the following have been done: You must Indicate either 'Yes' or 'No' as to each of the following: Yes No / Pumping Information,was provided by the owner, occupant, or Board of Health. •None of the syz temcomposvnu.kaiw:beon purnped4or✓a2Jaast vwo xweaks an.&Lhe'vystem hasbaac,..necalvuag ws.ul flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note If they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non sanitary or Industrial waste flow. _ The site was Inspected for signs of breakout. _ All system components.Ycluding the Soil Absorption System, have been located on the site. ✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffle: "'TTT or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orr the site has been determined based on: _ Existing Information. For example, Plan at B.O.H. _ Determined In the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) The facility ownar.lard.n^i—pant If difieraat (root-0iacnar).►verar7rauiciad.wish iainrma2ioo:on tha proper mainwna ^f Subsurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropenyAddre": 54 Carlson Lane. West Barnstable Owner: Ann Burchill Date of Inspection: 6/9/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: /1 D g.p.d./bedroom. Number of bedrooms(design): '11 1 Number of bedrooms(actual). Total DESIGN flow 71 Number of current s dents:_ Garbage grinder(yes or no):-4e!Q- Laundry(separate system) (yes or If yes, separatalnspection.required Laundry system Inspected &or no) Seasonal use(yes or no): Water meter*readings,it available(last two year's usage(gpd): arse 4t AUN4' If well has not bee n Sump Pump(yes or no): 4 tested in past 12 months . It should Last date of occupancy: ! be done at this time . COMMERCIALANDUSTRIAL: �� Type of establishment Design flow: d (Based on 15.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present:(yes or no).&-2/ Non-sanitary waste discharged to the Title 5 system:(yes or no)/1/14 Water meter readings,If availa le: Last date of occupancy:- OTHER:(Describe) A Last date of occupancy: OW GENERAL INFORMATION PUMPING RECORDS and source f i for a io G /C System pumped as part of ins action:(yes or no) / If yes, volume pumped: gallons Reason for pumping: TYPE OF STEM 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) ZY I/A Technolog a c.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval. Other PPROXIMATE AGE of all co onents,date Instalfediif known)-and soume..of4nformation: ix �u uy9�ZZ Sewage odors detected when•arriving at the site:(yes or no) revised 9/2/98 Page 6of11 BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT II� of B.%.p� P.O. BOX 427 SUPERIOR COURT HOUSE > a t BARNSTABLE, MASSACHUSETTS 02630 u � PHONE: 362-2511 EXT. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sample wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. It is recommended to use a straight faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not (ill bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper) is S25.00. Checks should be made payable to Barnstable County. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information. 7. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday 8:00 AM to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Completion of tests and results takes 7-10 business days. Results will be sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM are available for an additional charge. Contact the laboratory for availability. NOTICE: WATER FROM THE SAIv>E SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS TI E COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS ACCURATELY PERFORMED, PLEASE COMPLETE REVERSE SIDE OF FORM PRIVATE WELL WATER SAMPLE DATA COLLECTION SHEET VOC VIAL NUMBERS FIELD BLA14K BOTTLE ID NUMBER DATE REC ' D NAME COLLECTION DATE MAILING ADDRESS COLLECTION TIME WELL DEPTH 'STREET ADDRESS YEAR WELL INSTALLED MAP/PARCEL TELEPHONE COLLECTED BY : SAMPLE APPOINTMENT NEEDED ? REASON FOR TESTING: ( ) SUSPECT A PROBLEM (EXPLAIN) ( ) REQUIRED ( ) FOR INFORMATION ONLY ( ) 14EW WELL ( ) REAL ESTATE TRANSACTION ( ) OTHER (EXPLAIN) DISTANCE OF WELL FROM POSSIBLE CONTAMINATION SOURCES (IN FEET) : SEPTIC TANK\CESSPOOL FARM SALTED ROAD UST LANDFILL INDUSTRY GAS STATION OTHER TREATMENT USED: ( ) NONE ( ) WATER SOFTENER ( ) FILTER; SAMPLE TAKEN BEFORE/AFTER TREATMENT (CIRCLE) RESULTS *********** ********************************************** VOC ROUTINE CHLOROFORM PPB) TOTAL COLIFORM\100 ML 1, 1 , 1 TRICHLOROETHANE (PPB) PH CONDUCTIVITY IRON (PPM) NITRATE-NITROGEN (PPM) SODIUM (PPM) COPPER (PPM) ANALYSIS DATE: ANALYSIS DATE: f ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PtopenyAdaes.a: 54 Carlson Lane, West Barnstable Own e: Ann Burchill . Dsu of lrtspacticn: 6/9/9 9 BUILDING SEWER: (Locate on site plan) ter' Depth below grade: -i b Material of construction:_cast Iron/40 PVC_other(explain) Distance fto privato water supply well r suction line - Diameter 77 _.. Comments: (condition of Joints,venting, evidence of leakage,-etc.) Join . S&fi TANK: (locate on s)ts plan) Depth below grade: Material of construction: _.,/.ncrotgA//fmat"> iberglassJC�Polyethylenel✓/ether(explain) If tank Is Instal,list ape • Is.age.confirmed by Certificate ooffjCOmP once_lYsslNo) Dimensions: 2Xil1A Sludge depth: - Distance from top of Judge to bottom of outlet%so orbrs fle:j:=L.�. Scum thickness:-!�/ Distance from top of scum to top of outlet toe or batfls: r t Distance from bottom of scum to bottoof o tist tae,orb ptfle:A� How dimensions were determined: Comments: (recommendation for pumping, condition of Inlet and outlet tees or•bafiies, depth of liquid level In relation to outlet invert, structural-;rttogrity evidence of leakage,etc.( 'P"mP tefilt every-2-5 years . n e t outlet t ees evel at e outlet invert is fifty is structurally and and shows GR o ea age. (locate on sits plan) Depth below grader Material of cons uucti on Vj&oncrat.) mstalX/AFibarglassl&PolyethylensiVAtha(Iexplain) Dimensions: Scum thickness: Distance from top of scum to top of outlet too or batfls:_6/ Distance from bottom of s to bottom of outlet tee of batfle:-40 Date of last pumping: Comments: (recommendation for pumping, condition of Inlet and outlet tees or batfles, depth of liquid level In relation to outlet Invert. structvra)inteprit) evidence of leakage, etc.) Glt:abu Crap is not present - revised 9/2/98 Page 7orII r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addreaa: 54 Carlson Lane, West Barnstable Owner: Ann Burchill Date of 4upecdon: 6/9/9 9 TIGHT OR HOLDING TANK,& {"Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade:AM Material of construction/ concrete4Ai metal#&Fiberglass1//?PolyethyleneAAother(explain) Dimensions: AM Capacity: gallons Design flow: gallons/day Alarm present Alarm level: A Alarm In working order:Yes/fj No W Date of previous pumping: IVV9 Comments: (condition of Inlet tee, condition of alarm and float switches, etc.) present . DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: ie•if level and distribution is a qual, evidenoe of aol)da carr over, evidence of leakage Into or out of box, etc.) 5gtistribution box flas One latera"Mo evidence of solids carry over . No evidence of leakage into or oltt of tha bnX _ PUMP CHAMBER.-60e (locate on site plan) Pumps in working order:(Yes or No) Alarms In working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop-rcyAd&—: 54 Carlson Lane, West Barnstable Owrw: Ann Burchi ll Date of Inspection:6/9/9 9 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,If possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: J leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields, number, dime lions: overflow cesspool, number: Alternative system: Name of Technology: ��Ei' Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Loamy C1Ry hAcA SAnd to ;ed-iem eearseerrs—N-o�rrs uf re Cry. Vegetation Tb�l-6I'7Tf CESSPOOLS: Q Q� (locate on site plan) Number and configuration: O Depth-top of liquid to inlet invert: Depth of solids layer: AIR Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of Inspection) Comments: (note condition of soil, signs of hydraulic failure,-level of ponding,condition of,vegetation, etc.) eesspools are not present . PRIVY:�y11 Z. (locate on site plan) Materjals of constructj n �l: 9 Dimensions: Depth of solids:-" dommentV (note condition of soil, signs of hydraulic failure, revel of ponding, condition of vegetation;etc.) Privy is nor- present . revised 9/2/98 . Piee9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con*x.+ad) PTop6ayAddi 54 Carlson Lane, West Barnstable O+rn.+: Ann Burchill D n.. o r 4up.coon: 6/9/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: Includs U&$ to atlaast two parman$nt rf($ffncs landmarks of bfnchmarks local$ all wills w1Wn 100' (Locals whiff publlo water supplY oomss Into h0u:f) I L I O 0 P )1 � lo z s z8 I I o _ revised 9/2/98 Pat$ toof11 I I JUN-09-1999 14:11 COTTON RERL ESTATE 509 420 3161 P.02.04 PI -an o Y � i i ® �`•s,•, �q N�y7 � r (r �0 •/ i / tv © 01 r �1" 07 Directions: Route GA to High Street,left into Bodfish Farms,first right onto Carlson,house on Left. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Carlson Lane, West Barnstable Owner: Ann Burchill Data of Inspection: 6/9/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater dFaet Pie:�Obtalned I dicate all the methods used to determine High Groundwater Elevation: from Design Plans on record pDet.�rmined e(Abuttert bservation hole, basement sump etc.) from local conditions ' Checked with local Board of health Checked FEMA Maps Necked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model ralt�/�� revised 9/2/98 Page 11 of 11 1a•wnn r.�n•r�'r'r•,anraaa•a.man."a.a.a'..a�+r.wn�.'•a.....�.�.+aaw..nR.,y nra�a+�n inn TOWN OFBARNSTABLE WARD OF HEALTH i ISUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CEIITIFICATION �_ 1-•rn-�••.•::.—t.in�...•.�mrw.•nn.n�,r,vrnrn"nn�:r-n�.nvewa�ww�r-r++�r+nr r'� Ian.I1TRTT.TTPnT*+�'.�.I•T'a�•�• —.•^ -TYPL OR PRINT CI.CARLY- PROPERTY INSPECTED STREET ADDRESS 54 .Carlson Lane West Barnstable ASSESSORS MAP , BLOCK AND PARCEL OWNER' s NAME Ann But. hill PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber, Jr. • COMPANY NAME Joseph P. Macomber & Son, Inc. COMPANY ADDRESS Box 66, Centerville, Ma. 0263.2-0066 Street Town or City Stat. LIP COMPANY TELEPHONE (508 1775 -3338 FAX ( 508 )790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that t11e information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ne : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the. environment as defined -in 310 CMR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have cona-cted has found that the system fails to protect the j-)ublic health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection for . a Inspector Signature CDate One copy of this ertification must -be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OLr IIEALI'II: • If the inspection FAILED, th'a owner or operator shall upgrade ' the eyotem Within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 306 . partdadoc r - LOCATION � SEWAGE PERMIT No. VILLAGE 14'[I/ t/�/ GL!V %�X'a�l �,P ✓7 �✓ �" r t 3 3— 0ce3 I N S T A LLER'S NAME & AD-DRESS ` r T R U I L D E R OR OWNER DATE PERMIT ISSUED ' ' DAT E COMPLIAN.C-E ISSUED 3 �S Ai 1 IM W44 NOyr FEB..............5,�............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH . ....................OF.....!&...��.'AS.%%913. :...........------------------------------. Appliration for Dispn.stal Works Tonstrurtiun Vainit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................"s .ir �.S: r� T �!:..� 6...<------ -------- .......................... Location-Address r Lot No. ._ Owner ��6 J/>�Hk`yam`�--- Address a ..�,1�'".-.."5� ■�?�'_.. —".!!� ��—---- a-'................... �:.Ll,��l�/�._���....-----._C� �lam" lY� �...__. Installer Address e� U Type of Building Size Lot.___43f � ®...Sq. feet Dwelling—No. of Bedrooms_______._�_______________________________Expansion Attic ( ) Garbage Grinder ( ) --- Other—Type T e of Building ______________ No. of ersons_._..__.______._____.___.__. Showers — Cafeteria a YP g --------•----- P ( ) ( ) 0.' Other fixtures ---------------------------------------•-------------------------------------------.-....-------..---------------------------------------------•--••. d W Design FlowNiquid _.3�_g....................gallons per person per day. Total daily flow_._.__.__�_..�_.()__________._.___._.___gallons. r WSeptic Tank capacaty_f®d_'�gallons Length.B.__�z..__. Width__._/O__. Diameter................ Depth...... x Disposal Trench—No_ ____________________ Width___f._.____._._._._ Total Length.____.____;.__.__. Total leaching area....................sq. ft. 3 Seepage Pit No.____._/.._.._._.__ Diameter_____ _ ________ Depth below inlet______._.._._.____ Total leaching area_._:Z _sq. ft. z Other Distribution box (I ) Dosing tank ( ) '4-,Z ��/� '&0 Percolation Test Results Performed by..�.A��_�_./est . �`�1_'7"K�________________ Date___2.-_Z�_'.:_�%_5'_.__.. aTest Pit No. 1................minutes per inch Depth of Pit.................... Depth to ground water__-_____-__-__________-- fi, Test Pit No. 2__:�___2-._minutes per inch Depth of Test Depth to ground watertYj?_T_/1646-fft'0 P4 ............................... ---...... =----------------------------- •--------________---------------------------------- _------------ ODescription of Soil ���'� ...•� --•••----•-••-•--•-----•--•---•••---•••-•-•---•-•-------•-•-••••••-••-••••••-••••-•-•--••---•---•-•-- cx� ------------------•------------- ..'.....-0,� ....✓.keei�._._.sn.��----------•--------------------------------•--------------...-----...........-------------- W •---•-•-••-•-------•-•-•----•--••-•--••••••••-•••-•---•--••--•-----------•---•---•--••••----•--••--•...••-•••--••---•------------•••-----••--•------...•-••••••----•-•-•-•--•---•-•-•••••.............. VNature 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 TMILE 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 of health. igned___._ IF--------- __-, Date Application Approved BY-•••-•••• = �`a �� Date Application Disapproved for the following reasons:--- ••--------------------------------------------------------------------------------------------------------- ••-----•-•--•••••••-......•••-•-•----•--......•-••----••-._._...-••-•--•---••-••.._..._..---••---•-••--..._......•----•••--•-•••----••-- -•-••-•-•-•.................................................... Dave PermitNo........................................................ Issued....................................................... Date T14E COMMONWEALTH OF MASSACHUSETTS . k BOARD OF HEALTH 4r1 av OF . Appliratiou for Btllpusa1 Works, Tonstrittfion pamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an hridividual Sewage Disposal r System at: .!.............. .Z U f �°e,1.2sw....-z4Mt-a�--------------------- Location-Address or Lot No. La n �, ,kOlrP•� �( :H d •f AAddress r� Installer Address Type of Building Size Lot............................Sq. feetIPP } Dwelling—No. of Bedrooms........_21................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----------------------------------------------------.---•-••••-----------•-•-----•-----•---•••-......---•--•---------•------......_..------•-------- W Design Flow....flOy_ _ _...........gallons per person per day. Total daily flow.......3�32?.......................gallons. W Septic Tank—Liquid capacity ............ © .. _gallons, Length_ `.' Width._`/P f. Diameter......... ...... Depth....- � `� xDisposal Trench—No..................... :..::...:...:. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........i......... Diameter.._... ... Depth below inlet......(z........... Total leaching area ...sq. ft. z Other Distribution box (j ) Dosing tank ( ) 2 7 Percolation Test Results Performed by....../N.<.,L-_ z!? ....................................... Date..Z. Z.Ft_.__c --------- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water................_....... 44 Test Pit No. 2..K_ ...minutes per inch Depth of Test Pit;..� ;. ._..: Depth to ground water_&2-T .EAC116V a •----•----•-----------------•-•••---•-•••-•--••-.........--•------•_.._....------......------.....--......................................................... Description.of Soil......... . .... ............................•----------------------------- -•---------------- v - -1 p-�..�2-r< - ���---------------------------------------•-----------......-------•...---•-•------------. U Nature of Repairs or Alterations—A_nswer when �lapplicable.......`i1.�0__..- :_`l_.�_.d- /l!__-•_.E- _ #i o.....11iE'_��,.?-Fr____.___�y---, ----K-4..1.� �.N-•-----•----_..--•-•-----------•................•--._......_...._...........--...__._..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 Compliance has been issued by the board of health. Signed--• e•--- ,-y......................................... Date Application Approved By. .....- � ,_ !'....�_•�,,......................... --- " •,� �? «� ate Application Disapproved for the following reasons-------------------------•-------------------------------------•----•--------•--•---------------••-•--•--.------ ...............................................•-----•----••-•-----------------•---------•----•---••............-----•......•....----------•-•-•------•---•--•--•--••••••...--.._.. ----......---- Date �. PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........o...-�... .............o F........ ......2.v57fF�L.................................... Tntifiratr of Tnntliliatta THIS O,.C.ERTIFY, That the Individual Sewage Disposal System constructed (,k' ) or Repaired ( ) b •; .C.ih - _ �"""� Installer - - at-•-.._..�._...... .....___C ....... �c 1�1 --�". "t-� ......''�- '"°`..'-�......'.-------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit . ............. dated.... ._.. _, ................ THE ISSUAN E OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL,F NCTI N SATISFACTORY. DATE...................... .�.... .__...... Y Inspector.---•---- . ... ..�. ,_..:, . .. THE COMMONWEA NTH OF MASSACHUSETTS BOARD bF-1KItALTH ................0F....... !9 it]$T/9T�jZ- .................... No .......... .......... �`y� FEE. .:mr:::'......... -Ehiv s nrkp Taanstrnrtion rrnttt Permissionis hereby granted------. ................................................................................................ to Constr ct ) or\Repair ) Jndrvldu4 Sewage isposal System JAP p. at No. �. .an ' - �� Street �t- .� � �� as shown on the application for Disposal Works Construction Perm>t �.-:+ _._.._.=_._.: Dated,` ,2_ ........................ _., II _per Board of Health DATE... ... J ................................................. FORM 1255 A. M. SULKIN, INC., BOSTON ? �G 2 o t rn in. f fop Of _ - ----- �_ min. Conc. covers 4" cast iron or �;`;; `� 2� layer of Sch. 4o PVC, .. �8��- pipe WlMirlf— washeal p%fcf7 V4 Per" �,� foot .:: 4 p 5��. yo „a p;P e1 •f/ow line c/ea.n S C) AI-q- s ° ;• . irty. e/ precas ' • �JG/STjlyl ) �' Inv.a ;may•cF•ushed1 qg ° ° ° � ° • • �/ . . -��. !%Ct - - `•-'`+/;i��^ - l�.l rL �J�{`" �`.lV._... __ �W��' -L. t 1 ° w • w �I t •• I ° stone base inv. e% °•• - - ° inv. e% �-i c an/�C ., j ( j �CxS�F!-E inv el. • °° . °. 4 - / _ o _ • ° °� �;;• —.. ..�` > 4 - 5 Y2 shed• T ne ;stone;base:;•� o(isf: �� � >C in v. e . orourad wafer 71Lab/e elev. = itloy O bo#orn fesf hole. e v./e 10 CDoo SEWAGE SYSTEM P� P/L E' \ 1 t^ not -`'o sca/e_ oT \ � N � ATi9 E SIG NUMBED- of aE0ROO"S _ TE S7- H L O G GA.eB,9GE O/SPOSAL UA//T : TEST G7ATE� : 2" M PLE d A\ �n TOT EST/MATED FLS�,W W/TA/ESSED 6Y: „ o �%' � GAL.�B12.�DAYxs2 Bl2� : PEi2COLAT/O/I/ i2ATE :G MIN.//ll/GH 1----bl 2 MAPLE \\ LOT 15 7�'ERj=Op'Af E� -3 : /� { {ram ^ _ 43,940 SFt i2 E Q• SEPT/C Tj�9Nl'� CAPACITY: GAL. How E 1 HOLE Z 6 2" PLE ° O /. rgCTC/AL SEPTIC TA/VIe- SIZE : { L E A c141 AJG ARC- i2/ U/ Y SIDE WALL Z !ZJwr IST AL. ` 6„ TREE cA AGE TOTAL LEACH/NG CA A C.01 Y nn VvIC�. Zp )eES6.RVE LEACH/LING CAP 1TY 11g,36 / ,� �b ►�fo 2, ORE a AY W N O T C S IN , � � E sT \� I� ALL W0R/<MANSH/P AND MATERIALS RCH s if)(RE7IN) `` SHALL COnJFORM TO Zg;E.P. T/ 8 \ �� � \ AND THE ToWA1 OF �13 h'T14� o N RULES 13NO i2EGULAT/O/VS FOR P P. ' SUgSU)eFACE 0/SPOSAL OF PROP. �. S A N 7r' 1A/2Y E S WA G E. P .� y /i% Z� COMPLIA/VCE WITH ZOAJIIVG eE-GULAT/OIVS , g EXISTING `� i �, SHALL gE DE-TE,2M/NED BY SLJ/LO/AIG ly Y_ HOUSE IIVSPE CTo/2 COM1�/SS IO/VE�2• LOT 11 ry TF=51.75 3) EXISTING AND FINAL. G�EADES S14,gLL � FF=52.54 4 R-EMA1N ESSENT/ ALiL.Y THE SAME. W�I,t,Lj t�YN ISO �f ���� 3 - 6A6 OW I 481 �F'h e�` ,°`D '> /h/.57��-�-Eg —47 �, �b o� T H �LC�G.�9?70�c.� b�' ,q flj' 0 ,9 T E- A P P)e o v& o : �,, cSF WE2 /A'/Vti.S �' cSHX* Af LD. OF HE A L T H 5' EEC,/ 70 D S 7-E PL_ Al`/ of PA2 OfPO S O G OAJ ST UCTIOAJ L OCAT/O/V : S / TE- PLA /V � E-FERE /VCE- : ►'�1 !3 �� #� P R E P A 12 E: O F O i2 LT/ 12 S C A 4- �t7V,, Z• 20J - kk OFDAVID ,ygssq 3 I=-Aj 9A-1 q. r,5PjE;q/r/V6k/ ( B. G -fyp• existinq Spot- elev. - O.o MASON eXistimq contour cru>ZVIE' '7>/V v � o ~I W y' (,� yP. prop. f pat- e/ev. o. o c �t7• S prop' %r,. confovr = o o f -f-esf hole location / W L 0 A ET I P P A-1 MA 8 — - �Ja • S011 LOG Too of NtL..E 'Tc/� or- wc�� -L 7s• o NO. 1 N O. 2 EG 72,SITE PLAN ! ToP;u i� 1 2 1 sC/3 5,0 - TOP OF FOUNDATION EL.: __ 6 c -I wLL 7 oo' IN.EL. 72. ) 3 10 — • ° •• 7 39 A41L)llWUfkf 1, CIavEFZ ` - IN.EL. 7i• S` =--�-� _ I WASHED STONE 11 -r-� IN El r — --- i 3 8 W • . — _ —_._ — • ► •r :. 2 COVER /8 ,. F� �3.0 IN.EL.��'$`� a IN. 7/. 7L v cl o ° o / O 6�LL7 12 F=,�,,1 ° -- - _— - 13r •• D/B W/ 6" SUMP IN. EL�� a� a000�o 3/4 1 1/2 WASHED STONE PNGocuvTLr��D _.�� 4' LIQUID LEVEL ; ° ° ° ° 14 O a e o o 6-E ff. DEPTH• o° o i 15 E—� C�,av� rc�E� e --• - �, •. ° ,% Q o v b • �` b a PERC TEST RESULTS °p O OOO(`7 • PRECAST SEPTIC TANK WITH °eo o� o �• PERC RATE : _" E55 -�r,� - PRECAST LEACHING PITS. CAST IN PLACE INLET AND EL• Z. �7 �o� h 6 ° ° NO.: ! _ SIZE : �`A i" 'cs''��- r}PTa - WHITNESSED BY: OUTLET T 'S PER TITLE g . BOARD OF HEALTH DIA - QF SIZE . �� ,��� A� �a � DATE: 3_2e -_84 REEF' �- -- -- 8 DIA. --'1 o,V PROFILE OF PROPOSED SEWAGE SYSTEM SYSTEM DESIGNED BY THE TOWN OF _ — _ REGULATIONS AND 9 FAQ•_; s.. .. y '` " �L 72.6 i STATE TITLE V FOR S�UFPSURFACE DISPOSAL OF = SEWAGE . SCALE 1/4 = 1 0 ,, _�; 4,r / - N . B . 1. All PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE 2. All PIPES SHALL BE SLOPED 1/4 PER FOOT EXCEPT FOR THE FIRST 2 FEET OUT OF THE D / B WHICH SHALL BE LEVEL 3. DESIGN FLOW BEDROOMS AT 110 GALDAY PER BR . GAL/DAY SEPTIC TANK SIZE -______ X -_` = __49S GAL . 1 A USE 1092 GAL. W/ 01 GARBAGE DISPOSAL431 •D • TA ON. LEACHING SYSTEM : USE rig - D,A . x �� 1-fr: LePTt; r"«"..,r� ��T +�.�/ t'-c�'' car � rc�r-► ��-5 Asrc�v��T:� 6 , sT -"�Ct�'.,• ELT�� EFFECTIVE AREA : SIDE y �� z �=� �� xis GAL 't>& �i. /}cL e 5 :r ' BOTTOM Ive, l '� L ` TOTAL FLOW - �_ ._ :��; � s•s ��: j� ` p Fa TOTAL REV O FLOW -2 X "• .0 = - W/___ _ GARBAGE DISPOSAL RESERVE FLOW ..-- - AL/DAY 8 e ; •:� v 3�8 .0 REFERENCE PLANS : ",SCD�r7lf;H Z �&M' ���LJV s,rA.. AJ �c r�E ini��.FirrG fcG 2-8 9f 4 ' APPROVED BOARD OF HEALTH DATE : ,-- PROPERTY OWNER : ��f,�./ ���e�E7, rti�. __ SITE AND SEWAGE PLAN R. 6x_ a-lf o ,�'' �� FOR : z3 G oE'.rE Iry c. l✓EST t3.te vs?� MR Ss, o,, `E' c + .t�'; T �� KO �sy � BEDROOM SINGLE FAMILY DWELLING ------ ---- -- — -- ------ ---- — f A . y � ;; ���� �.�' LOT : ivo is DATE NOTE; his L-UT TxUr_ l�lG'►• ! �N 374.UeDL P4AIf4- °NA`E; ' DOYLE & ASSOCtATES FALMOUTH , MASS . h