HomeMy WebLinkAbout0191 CARLSON LANE - Health 1)I Carlson Lane,West Barnstable
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No.- -- '7----`3� Fees---------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
���ritation,�or�eri �Cori�tructior��ertuit
//0 --P?-7
Application is hereby made for a permit to Construct (Alter ( ), or Repair ( )an individual Well at:
--I - — -- - -— t —�--—__------- -- --- — -- —_P__—_—_— —
L cation — Add res Assessors Ma and Parcel
So tV
�'CJ
---------------------------------------------------------
Owner ^ Address
-------------- -------------------------------------------- -------------------------------------------
Installer — Driller Address
Type of Building
Dwelling----------------------------------------------------------
Other - Type of Building No. of Persons----------------------------------------
l( -
Type of Well--k/ - Pr%/G --
Purpose of Well - D__ ----- ----------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of alth Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation unt' a Certificate of Compliance has been issued by the Board of Health.
Signe - - - - - ----------
- ------- ------------------
date
Application Approved B G� ' r� --- - - --�- - --� f�____
PP PP Y--- ---- — d e
Application Disapproved for the following reasons:---- ----------------__---------—_______—_ --__--___—
date
Permit No. -- —1- 9=--- - 1�--- -- Issued -- --—---L— �- —------—
ate
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifitate ®f Compriante
THIS IS TO CERTIFY, T t he dividu 1 Well Constructed (Altered ( ), or Repaired ( )
by _-_-___-_
— —-- - -- -- --
Installer
- ---------------------------------------------
Al
at
V LCM—A
has been installed in accordan4— 0ce with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No !!- ,. 7-'L.Z(OebatedTHE ISSUANCE ISSUANCE OF THIS CERTIFICATE SHALL NOT T BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ------------------------- ---------- Inspector-----------------------------------------------------—---------------------
No.y_ •' w� ." '- Fee ---------------
17
BOARD OF HEALTH
TOWN OF BARNSTABL- E
RppficationArVell Con6truction3permit
Application is hereby made for a permit to Construct (L Alter ( ), or Repair ( )an individual Well at:
S t Location — Addres Assessors Map and Parcel
Owner Address
___—_--------—------------ --------____—_--
N ` Installer —,Driller U Address
f
Type of Building j
Dwellingi- ----------
Other -.Type! of Building ------ No. of Persons---------------------------------------------
g-------------
-------
Type of Well Y` I IP/ --— - ------------ ------- ___ ---
YP —r , —— Capacity - - t J
Puipose of Well---- QAi�---------=------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the-well in operation until a Certificate of-Compliance has been issued by the Board of Health.
Signe
�t
date
Application Approved B dke
Application.Disapproved for the following reason s- __________________________—___________________--__ f
— date--_—_—
Permit No. -- 1 � -. --'—` _— Issued---- r ante
•date -
BOARD OF HEALTH
_ TOWN OF BARN-STABL`E
(Certificate ®f (Compliance
, THIS IS TO CERTIFY, Th t the jIldividual Well Constructed,( Altered ( ), or Repaired
- -- - --------------------by------------- _....___ _
-------------—------------------------------------------------------
�" Installer
17,/ f4),4 rx
has been installed in accordance with the provisions ons of the Town of Barnstable Board of Health Private Well Protection t
Regulation as described in the application for Well Construction Permit No/V--'A-;OL Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT.THE WELL
SYSTEM WILL FUNCTION SATISFACTORY. .. Al
s
DATE--------------------------------- ------ Inspector---------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN , OF -'BAR.NSTABLE -
Veil Congtructionpermit
No: Fee- ------------- 075-
Permission is hereby granted _ - ------------------------------------------------- —to Construct-(Alter ( or Repair ( ) an Individual Well a
Street S �
as shown on the a,plication for a Well Construction Permit : - a
k a-
No.- -- -- — -� - -- ---- Dated
01� -- Board of Health
� DATE----------------------------r-----�----�---=�------------
V
pp-
ar.' Depai'mient of Environmel tal Managem%nt/Division of Water Resources
WELL COMPLETIOiV -1EPORT�,,r
.IIµ.u.-•,`e ._ ✓
WELL L CATION GEOGRAPHIC DESCRIPTION
Addres —
.S rtAl1� ( S E W of
peer) (circle)
City/Town — LSo 71/jam"l
Well own Ar O/
� 5� C R '(road)
e
Address QSi' Q dkJl�a N S E 0 of
(mr rn ten s) (circ
Board of Health permit obtained: yes no,[:]'
ul(ersect. w/ Y oad)
✓.
_ WELL USE WELL DATA
Domestic Public❑ I
ndustrial ❑ Total well depth_ft.
Monitoring❑ Other Depth to bedrock —.ft. r^
Water-bearing rock/unconsolidated material:
Method drilled jeC, 'Description y'd
Date drilled
Water-bearing zones:
CASING 1) From ' To X
Type ry el 2) From To
LengthJY_a-ft. Dia(.I.D.)__V_ —in.
3) From To
Length into bedrockft.
a I -Gravel pack well�Q dia. r
Protective well seal: q,0Screen: dia.
Grout_❑ Other Slot�' lengthfrom to/�LL
STATIC WATER LEVEL(all wells)
Static water level below land surface ft. Date
WELL TEST(production wells)
Drawdown-Z—ft. after pumping hr.;9Q_min. at 46 gpm
How measured 'NAA _-Recovery ft. after_hr.14min.
• a.
LOG of FORMATIONS COMMENTS g
Materials • From To
Driller
d 4,cL Firm
Address/•l ,M n7�
1I City/Town t(d
T Supervising Driller RegA
Si natureofstopt in registered w&ll driller
P)°esa print rirmly BOARD OF HEALTH COPY
t
� ASS ! � � ' 6•� 7
YnB lea
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
W
3 J
Appliratiou for DispaiiFal Works L Umfian l
CERTIFY uPERvisl-
IN ;
Application is herebyINSTALLATION AND WRITING:
made for a Permit to Construct (�) orf pB*STEN1 WA8i&WMLE&1WSff19j;�sal
System at: ACCORDANCE TO PLAN.
..1.4.�...�1A i�,.�5.(�.... .:... :. L........ ...-�. .......�n A:�4 -----------
Location-Addres o ,
/lOwner /•,, /r•. (� r Ad �s Q
►�iT/I �.. r ....5C-'/'!`!!f.C............. .... 1!......k x.......4.K.t ................................
Inst r Address A
Type of Building Size Lot................&.._.__.Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (NDQ
Other—T e of Building No. of persons............................ Showers — Cafeteria
04 Other fixtures ----------------------------
440 W Design Flow................515.................__gallons per person per day. Totalyd;il flow.....440---.--.--.-.--._.__....-. Ions.
WSeptic Tank—Liquid capacity19.o_-gallons Length)l'"-G....-.. Width.p-- � Diameter________________
x Disposal Trench—N o. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----___2_....... Diameter........ Z.`... Depth below inlet.._...G........... Total leaching area...01g...sq. ft.
Z Other Distribution box ( ) Dosing tank ) -P—3{G 5
~" Percolation Test Results Performed by..... .L�.__.K... -�..--------------------- Date... ......._.
,aa Test Pit No. 1......2-_---minutes per inch Depth of Test Pit...._._,. .°..._ Depth to ground water------
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
--- ------------------------------------
--------------------
-.......
----------
•-----------------------------------
--•---------------
O Description of Soil.O" �•l.T_$ Q��►--------------- ...
----------------
x ------------------------------------- ---••-•-••-•--------------•-----•-•-••.....-•-------••-•-•-•••--•-•--._.......••----•-•-•-•-••------•----•--••--------------••------••----.......................
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
------------------- ---------------•------------•----•----------.....................................................--------------------------------------------------------------------------------•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of '� .LE 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance hastb/eDnspu e boardX' G
t_ivUINEER MUST SUPERVISE
TION AN CE IF RITI(\C'
Signed. �db
........... . !R&LYKkrqN�WI. —ST-R 7
�A.000RDANCE TO PLAN. Date
Application Approved BY---------. J �1
----------------------------------------
Date
Application Disapproved for the following reasons---------------------------••-------•-----------------------------------------------------------------------_...
---------------------------•----------------------------•----•------......----------------...----
Date
Permit No.------ ----------------------- Issued......... .�"-1 __-_�... ---------_---
Dste
Ass FnB
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........?• ..1k,.........OF........ .�°.:.�� °.°.:�. ..,.•• - .........................
Apphrtation for Disposal Works Tongtrurtion rrmit
Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal
System at:
! rl i 1 t i
r r
-r
Location- ddr s I,ot No.
Own��o� ~/Q1/a rressss -,.-•................•........ :... T/.= Cam•-- [ u�* ...........................
j........................
J� /+nstaller Address
of p
Q Type of Building � Size Lot--------- feet
U Dwelling—No. of Bedrooms.._.........I..............................Expansion Attic ( ) Garbage Grinder
Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fi�prps . 'ell
W Design Flow................1 `' � .....gallons per person per day. Total daily,�flow----- ..._.........._.........__ llons.g
WSeptic Tank—Liquid capacrty�,,t� gallons Lengthy .__ :_._.. Widths . Diameter................ Depth.. '. .. '
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
m r_--- De Depth below inlet.__._c .___.__.__ Total leaching area sq
ft.Seepage Pit No.___---- -____-_ Diaeter........ -
Z Other Distribution box ( ) Dosing tank�( 1 ) >
Percolation Test Results Performed by .. _g_�__..f F._.. r Date---
...........
Test Pit No. 1................minutes per inch Depth of Test Pit-------- ------- Depth to ground water------_�._..t.._:_,r
(% Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
a -- . ••-•--...••• ---- -- --•--•------------------•----•---...._...........------
Description of Soil . 1 s )Y `---•-----•- •-••••••••---•-----••-••--•-••-----------------•---
O y�
x ' t 1 � �" 3
U -.............••---•---••. ---�-- ---- --g•- .. . .. -- - > ZQr
W •---------------- ----------------------•---------•------------•-•--------------------••-••••-•--•-•---••-------------------------------------------•--------------------------•---•-•-•-••--•--•--•----
UNature of Repairs or Alterations—Answer when applicable................................................................................................
----------------------------------------•------------------•---------------------------------•----------•----------------------------------------------------------.._...----••---•--•-•........-----•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T T I.
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has 4eqn issu y the board of alth.
Signed -------------------------------------
Date
Application Approved Bae_ ,J.._ c�..•-----------------------------••---•-- --------------------
PP PP Y ---- ---------------
E- } Date
Application Disapproved for the following reasons:................................................................................................................
.........••--•----••--•--•-•---------••---•-••-•.....--•-.......-••••.......................•----•-----•---•--------•-•------•.........----............................................................
Date
Permit No....... .. v----------------------- Issued-.........�.� - ..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
C9rrtifirFatr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---------------Paz,, t----... �� _ .�c . ...................I. .......-----------------•-•-•---•-------•-•-----------•----------------•-----•--•---------....--------
nstaller
has been installed in accordance with the provisions of TITIE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit ............ dated--------------------------------------4..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................................................••--•--•------....... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. 1--..........OF........ ��h.- nz�4 1........................................ l
NO......-- ...3 -3 FEE....A2.1............
Disposal Works Tonstntrtion Wrmit
Permission is hereby granted.......R/.' -4---- 14, � --••---------------------------------------------------------------------------
to Construct ( or Repair ( ) an Individual Sewage� iT3 sp sal System
atNo.--- / c- ' z_. ------ -------------------------•-••-------•----•-------.--•------•---------------•---•---------•--
Street
as shown on the application for Disposal Works Construction Permit No,4 :.__ J___ Dated..........................................
........................•----------------------------------------------------••••••-----••-----•--••----
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT
VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS
Client: SANDRA KRAFTON Collection Date: 06/20/93
Mailing Address:P 0 BOX 1814 Date of Analysis:06/23/93
SANDWICH_MA ,02563 Type of Supply: WELL
Well Depth (FT) : 140
Telephone: 888 *4180
Sample Location:191 CARLSON LANE LAT. (DDMMSS) : Not Given
BARNSTABLE LONG. (DDMMSS) : Not Given
Collector: DEBRA KRAFTON Map/Parcel : LOT 8
Affiliation: WELL CO
,Analytical Method: 502.1=1 , 502.2=2 , 503 .1=3, 504=4 , 524 .1=5, 524 .2=6,
50.2.1/503-7
Contaminants Anal . Result MCL Detection
Detected Meth. ug/l ug/l Limits (ug/1).
Chloroform 2 9 .6 0 .5
Only :those compounds listed above were detected. Attached is a list of
compounds for which this sample was analyzed.
NOTE:,Con.taminant levels equal to or exceeding the Detection
Limits are reported.
MCL means . Maximum Contaminant Level for EPA-regulated
compounds . (ug/l = micrograms per liter ,= Parts Per Billion)
The. Environmental Protection Agency has set Maximum Contaminant Levels
(MCL) for the following compounds. This sample compares as follows:
COMPOUND MCL (in PPB)
Benzene 5. 0 * level not exceeded
Carbon Tetrachloride 5.0 * .level not exceeded , *
1, 2-Dichlotoethane 5.0 * level not exceeded *
1 ,1-Dichloroethene 7 .0 * level not exceeded *
1 , 4-Dichlorobenzene 75 * level not exceeded *
1 , 1,1-Trichloroethane 200 * level not exceeded ,*
Trichloroethene 5.0 * level . not- exceeded
. Vinyl Chloride 2 .0 * level not exceeded
Comments or. additional compounds found:
+ Thomas F. Bourne, Laboratory Director
TOWN OF BARNSTABLE
LOCATIONS �� l� �F'� '�+f'r li— V SEWAGE
VILLAGE ASSESSOR'S MAP,& LOT /0 . 6 2-7
INSTALLER'S NAME PHONE NO. f 4 r�y ,
SEPTIC TANK CAPACITY ate
LEACHING FACILITY:(type) size)
NO. OF BEDROOMS r PRIVATE WELL OR PUBLIC FWATER
BUILDER OR OWNER � 1
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: I b 1 s-
VARIANCE GRANTED: Yes No
a4N
I � r
` ' `
Log Number: Bottl e # 094401 ..-Date.: -'6/21/93 .
' of B�ti
�, sa BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT
,-_SUPER1OR.000RTjHOUSE
BARNSTABC ,'MASSACHUSETTS'0-
O
MA55 630
DRINKING WATER LABORATORY ANALYSIS :PHONE-362-2stt
---_Ext:337
Client: John & Sandra ;Krafton Col lector: : Sandra Krafton
Mailing Address: 98 Quaker -Meetinghouse Rd Affiliation: Owner77—
East-:Sandwich, MA. 02537 Time :&.;Date of _
-Collection. 6/17/93
Telephone: 888-4180 - .-Type :of�.Supply:°_; ,t. -Wel l
Sample Location: 191 Carlson Eane, Lot 8 Well Depth:
West Barnstable, MA. 02668 Date of Analysis: �17/93 10:45 a.m.
PARAMETER SAMPLE RESULT RECOMMENDED LIMITS
:O
Total Coliform Bacteria/100 ml - 0
H 6.2
Conductivity (micromhos/cm) 61 500.0
Iron ( m) 0.3 0.3.: _
Nitrate-Nitro en ( m) 0.1 10.0
Sodium m) 5 20.0 -�
Copper (ppm) 0.3
I . XXXX Water sample meets the recommended limits for drinking of all above tested paramete-
II . Based only on results of the parameters tested for this sample, the water•,is -
suitable for drinking but may present the problems checked below:
A. Water sample has higher than average, levels- of Nitrate. Future monitoring -is
recommended (2-..3 times per year) to establish any upward trends.
B. The low pH of the water may shorten the useful life of the house's plumbing.
C. Water may present aesthetic problems (taste, odor, staining) due to
D. Water sample has high levels of sodium. Persons on low sodium diets should
consult their doctor.
III. Due to one or more of the reasons checked below, this water sample exceeds the
recommended maximum contamination level for drinking water:
A. High Bacteria B. High Nitrates
REMARKS:
Iron at limit
CC: BOH
Laboratory Director
1 /7/85
•atia n'. -f`F- t r�x ;a+ ♦ .4,� _ a 1 W7 �: ]p•^Ny1T 7� Z` "Y, .'#T` :...` 1�4r'm",1"k�,sr� a.�t}� +$.�.ai,'By'�, �7tw
.v
a a y� �5".(. �•,. .e3 (' (]A� a;,M bf.� t�� s4^.,�, ,1 4 r .r' e�,� 11 '�
`i:_ e a, . . tee° e I..;,
&1;d3�i�VYL•3�iq..wY1... .�ri.s.ff �a•��� 5'E��sNr�3� w 3"7 ,�s ,a¢�'. �"Y '.�. f �f3.,1�.�+.�1IJ
ExplanationofTestResults
_ T6tal Coliform Bacteria w _��Ai l'�
- ColiforMObact'dria`are�'an indicator of the:sanitary quality of,C water rsuppf} Water'Isupplies may :becorime
contaminated from malfunctioning septic systems,.cesspoolsrand.surface runo iAi'total?coliform cotint:of:zero i
indicates that your water supply is safe and approved:for human`consurription,.rAEtotaL eoliform count of greater than
__ _.
zero is most oftemthe'result of accidental contamination of the sample bottle through improper sampling methods.
---For this reason, it would t advisable, refest any well water that is not~approved PS ;g;;dqe}gY
f `T 'i; , �' 9El15 f 0_2 'YbU �n F
.rnH cl�:0 Cif .v : . ,.+ �, 15U 8 SO _P� i 9�clF5t2n^r68 J2CW
p s
�pH is the measure of acidity oralkalinityof the water.On the pH scale,the number?is neutral,less than 7 is acidic.
and more than 7 is alkaline. The pH of water on Cape Cod tends to be acidic iri[the.range,ot-5.0,to'.0-5163r
Conductivity
fi V ilJ
Conductivity is a measure of the dissolved salts in solution.Amounts in excess of 500 micromhos/cm are generall}-
considered',unacceptable and may have a laxative effect upon users.
Iron -_�t__.._. __.. __.___' _..._.__._____ ._. • :a t
The presence of iron in water in concentration of .3 ppm or greater may: give the water a bitt'er'sweet astringent_.
taste, cause an unpleasant odor, often gives the-water a brownish color and cause staining of laundry and porcelain."
_. __.
The average concentration of iron in Cape Cod's water is .2 - .6 ppm._Although the presence of iron inwater nia\
cause the problems listed above, it is not considered deleterious to health. Iron may be removed by use of an iron
--.--..._.__... __......_---.__. . __.___.. _-. _..--- ---- -----------
re
mov.a system.
13.
Nitrate-nitrogen, ,.
The Massachusetts Drinking Water Regulations have set a maximum contaminant level for nitrates at 10 ppm.
Excessive concentrations may cause methemoglobinemia (an-infant disease) and have been:suggested to form
potentially carcinogenic nitrosamines. Contamination sources include fertilizers, cesspools and:industrial.wastes.
Copper .
Due to the acidic nature of the water on Cape Cod, copper tends to leach from pipes. This normally does not
present a health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a
bluish-green stain on porcelain fixtures.
Sodium
A concentration of sodium over 20 ppm is only of concern to people who are on a low sodium diet. If the water
supply has more than 20 ppm sodium,it is up to the people who are on such a diet to find another source of drinking
water or contact their doctor to determine if consuming the water is advisable. Concentrations exceeding 50 ppm
indicate that there may be ocean water or road salt runoff water getting into the well.
i
a A
commonweari of Massachusetts .John Grad
Execs 0fe Office of Environmental Affairs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
' Environmental Protection Teaticket,MA 02536
(508) 564-6813
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A el ,�
CERTIFICATION
APR
1 .s 19
Property Address: 191 Carlson Lane W. Barnstable Address of Owner: '04F 9,
Date of Inspection:4111197 (If different) U178Srgb
qRN
Name of Inspector:JohnGracl Cralton �fP
NT
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This inspection is based on criteria defined in Title y
_ Condition Ily Passes code 310 CMR 15.303.My findings are of how the system is
performing at the time of the Inspection.My Inspection does
_ Needs F rthe valuation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the
_ Fails I septic system and any of its components useful life.
/
�r
Inspector's Signature: Date: 4/13197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303, Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair, passes inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.)
_ The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 191 Carlson Lane W.Barnstable
Owner: Crarton
Date of Inspection:4111197
Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in Order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or 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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 191 Carlson Lane W.Barnstable
Owner: Crafton
Date of Inspection:4111197
D] SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 600. Please consult the local regional office of the Department for further information.
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 191 Carlson Lane W.Barnstable
Owner: Crarton
Date of Inspection:4111197
Check if the following have been done:
X Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
Na As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115/95)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 191 Carlson Lane W.Barnstable
Owner: CraRon
Date of Inspection:4111197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number cf current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: n1a
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last year.
System pumped as part of inspection: (yes or no)Yes
If yes,volume pumped: 1500 gallons
Reason for pumping: Maintenance.
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
4 years
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 191 Carlson Lane W.Barnstable
Owner: Crafton
Date of Inspection:4111197
SEPTIC TANK: x
(locate on site plan)
Depth bellow grade: 2'
Material of construction:x concreate_metal_FRP_other(explain)
Dimensions: L 10'6'H 5'7-W 5'8-
Sludge depth:4'
Distance from top of sludge to bottom of outlet tee or baffle: 23"
Scum thickness:6'
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: 12'
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
The septic tank and all components are structurally sound.Recommend pumping the system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: nla
Scum thickness:nla
Distance from top of scum to top of outlet tee or baffle:n1a
Distance"rom bottom of scum to bottom of outlet tee or baffle: nla
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
n1a
(revised 11115195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 191 Carlson Lane W.Barnstable
Owner: crarton
Date of Inspection:4111/97
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nla
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
n1a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
n1a
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 191 Carts on Lane W.Barnstable
Owner: Crafton
Date of Inspection:4111197
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rVa
Type:
leaching pits,number: 2.1,000 gallon leach pit
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number, length: Na
leaching fields, number,dimensions:n1a
overflow cesspool,number:n1a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The overflows are structurally sound and functioning properly.
CESSPOOLS:
(locate on site plan)
Number and configuration: nla
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: n1a
Depth of scum layer: n1a
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of groundwater: n1a
inflow(cesspool must be pumped as part of inspection)
n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
n1a
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: rva
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n1a
(revised 11115195)
8
t
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address.
191 Carlson Lane W.Barnstable
Owner: Crafton
Date of Inspection:4111197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Nct
� A
L
AA
AB 64
g8 rei
8c q
O �
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
Commonwealth of Massachusetts
upTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owners Name
information is
required for every West Barnstable Ma. 02668 7/21/2011
page. Cityrrown 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 Sean M. Jones
use the return Name of Inspector
key.
C y e Enterprises
�y Company Name
153 Commercial St.
Company Address
Mashpee Ma 02649
Cityrrown State Zip Code
508-477-8877 SI 4522
Telephone Number License Number
B. Certification
1 certify that 1 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
7/21/2011
Inspectors Signature Date ...'
The system inspector shall submit a copy of this inspection report to the Approving Autk grity(hoard
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 samit t#e
report to the appropriate regional office of the DEP. The original should be sent to the gyfitem.�vner
and copies sent to the buyer, if applicable, and the approving authority.
M
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09108 TiOa 5 Official Inspection Form:Subsurface ge Disposal System•Page 1 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t 191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
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:
The dwelling located at 191 Carlson Ln. West Barnstable Ma. is served by Title V septic system
consisting of a 1500 gallon septic tank, distribution box and 2 pre cast leach pits.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•09/08 rifle 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
page. Cityrrown 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 CHAR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
page. Cityrrown 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 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
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to dogged 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 forms
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 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
'< 191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
r
Commonwealth of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
page. Cityrrown 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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage private well
9 _ ( Y g (gPd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
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 I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
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:
original system installed 1993 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallons
Sludge depth:
4"
t5ins•09108 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
y< 191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 3'
Scum thickness
2"
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
10"
How were dimensions determined? opened covers and took
measurements
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 should be cleaned soon and again every 2 years as maintenance. Outlet baffle was intact and
in good condition,water level was at bottom of outlet invert,tank was not leaking and was structurally
sound.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every west Barnstable Ma. 02668 7/21/2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade: '
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owners Name
information is required for every West Barnstable Ma. 02668 7/21/2011
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
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was inspected with camera from outlet of tank,water level was even with bottom of both
outlets, no sign of past hydraulic overloading.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
page. City/rown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit(#3 on as-built)was found to have 4'of available leaching with no signs of past failure.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every west Barnstable Ma. 02668 7/21/2011
page. Cityrrown State Zip Code Date of Inspedion
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°t 191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
page. CityrFown State Zip Code Date of Inspedion
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
d
P
0
r
o
'7 1
13-1 q3'
,41 /bb
13.2 q1' 011
A3 i26'
/3.3 //o`
R-Y /0%,
Y 7-7
t5ins-09/08 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/21/2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+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:
The property is elevated considerably compared to surrounding area.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 191 Carlson Lane
Property Address
Linda Oberly
Owner Owner's Name
information is
requiredd for every West Barnstable Ma. 02668 7/21/2011
page. C4rrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I�
e
r. .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
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 A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett It/
use the return Name of Inspector
key.
Aardvark Environmental Inspections
ay Company Name
PO Box 896
Company Address
East Dennis MA 02641
City/Town State Zip Code
508-385-7608 S13742
Telephone Number License Number
B. Certification
C-3
I certify that I have personally inspected the sewage disposal system at this addle and that the
information reported below is true,accurate and complete as of the time of the inspection.ThiFinspegtion
was performed based on my training and experience in the proper function and majntenance•of on iRe
sewage disposal systems. I am a DEP approved system inspector pursuant to Section W.340 0�
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
03/11/13
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 under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title 5 official Inspe ' o :Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Oberty
Owner Owner's Name
information is West Barnstable MA 02668 03/11/13
required for every
page. Cityfrown 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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined"(Y,N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(E)tplain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface SLwage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. City/Town 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 mannerwhich will protect public health,
safety and the environment:
Cesspool or privy is within 50 feet of a surface wafter
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
tins-11f10 Title 5 Official Inspection Fomi:SubsuAace Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form_
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/day flow
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
I-
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 191 Carlson Lane
Property Address
Kinda Oberly
Owner, Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s).Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliforrrr 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 faded 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 Fora
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Obedy
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. Cityfrown 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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS,located on site?
® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins-11110 Tills 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. City/Town state Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings,if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 10/12
Date
CommerciaUlndustrial 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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for West Barnstable MA 02668 03/11/13
every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Wass stem pumped as art of the inspection? ❑ Yes ® No
Y P P P P
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
El Privy
❑ Shared system (yes or no)('If yes,attach previous inspection records,if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the 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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y< 191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
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:
10/15/93 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.0
feet
Material of construction:
❑cast iron 0 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: 1.2
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: 1,500 gal
Sludge depth:
3"
t5ins•11/10 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
191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
3"
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
16"
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 ❑fiberglass Elz 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 Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
rim W- 9
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 191 Carlson Lane
Property Address
Kinda Obedy
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. Cltylrown State Zip Code Date of Inspection
D. System Information (coot.)
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
Mina•11/10 Me 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. Citylrown state Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 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: ❑ 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/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 two 6'x6'precast pits surrounded by three feet of stone.The pits were dry with
staining half way up,there was no sign of ponding or failure.
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•Iv,0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
yt 191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. Citylrown state Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
191 Carlson Lane
Property Address
Kinda Oberiy
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to
at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate
where public water supply enters the building.Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
rear
43
71
108 77
91
106
126
110
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal.System Form Not for Voluntary Assessments
`( 191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0
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:
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:Subsurrace Sewage Disposal System•Page 16 of 17
II-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'( 191 Carlson Lane
Property Address
Kinda Oberly
Owner Owner's Name
information is required for every West Barnstable MA 02668 03/11/13
page. City/town State .Zip Code Date of Inspection
E. Report.Completeness Checklist
® Inspection Summary:A,B, C,D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r
DES l GN CR I TEPi A ; I NVERT EL EVA T I ONS:
GENERAL NOTES;
DESIGN FLOW, INVERT AT BUILDING,, io2.0U
1 . THIS PLAN /S FOR THE DESIGN AND (7U P OF FoU�Ti�v�10u BEDROOMS AT 110 G. P. D. PER INVERT IN SEPTIC TANK:
6. �To - ACCESS COVERS MUST BEDROOM EQUAL S-44�> G. P. D INVERT OUT SEPT C TANK:
U SS
CONSTRUCTION OF THE SEWAGE DISPOSAL FIRST 2' TO
� '
O .0 BE WITHIN IZ OF 3rJ
FAC I L I T Y ONLY. 'BE LEVEL FINISH ORADE �� GARBAGE GRINDER INVERT I N O I ST. BOX:
I0o
4 ` PVC MIN. 2` OF ,•
INVERT OUT D/ST. BOX: ' 1
2. ALL CONSTRUCTION METHODS AND SCHEDULE 40 o a PEASTONE SEPTIC TANK REOUIRf'D: INVERT IN LEACH PIT: q9 -00
MATERIALS FOR THE SEPTIC SYSTEM 1Q2�00 �f GAL, 101 ,5 i "t 4
3/4' - I 1�2' _ G. P. D. X 150� = 6d GAL. �I 5100
Id 111BO/
• <L BOTTOM OF LEACH PIT:
sEPT/c TANK 1 �� DIA. WASHED SEPTIC TANK PROVIGE`D; O GAL. ADJUSTED GROUND 'WATER:
SHALL CONFORM TO MASS. D. E. P. I 'ourLEr � q� nip STONE'
TITLE 5 AND LOCAL BOARD OF HEALTH 0' MIN.
F�-10 o-Box Z t
,. OBSERVED :;ROUND WATER: NOfJ�.
r��;Tat SIZE OF LEACHING F�„ILITY
REGUL A T I ONS. O
LEACH PIT$ REOUIRED: P. D.
3. ALL SEPTIC SYSTEM COMPONENTS LOCATED PROF LE NOT TO S(ALE'- �-t4 DESIGN PERC RATE =.__3.— MIN/INCH REVISIONS:
UNDER PAVEMENT SHALL BE DESIGNED TO 20 1 B1�Ri ti� 2 ''P 1 TS �CE�QUi i;4
'' PROVIDED: `rIT(S) W/ 'STN. NO. DATE R VISION
WITHSTAND H-20 LOADING. iof sPf-K-T OAm 3 F�'•
_ S/DEWALL 45?— S. '. X '(�,og = f 0 GPD
4. ALL SEWER PIPE SHALL BE SCHEDULE 40 -
BOTTOM., 7'.'L�c S. i. X 1''� "LLro GPD I
OR APPROVED EQUAL. TOTAL: G7 S. F. 1356 GPD
S01 L SGASf,Ar't A LtiAG 4-1 P 1"`S
n n MhS7 BfC. VV-glP)Eb �cT
5. BEFORE CONSTRUCTION CALL Dl G-SAFE TIa�C. T1 MIL Of GO►JSTAUC'S10K. SOIL TEST P / T A TA �
I-800-322-4844 FOR LOCATION OF
UNDERGROUND UT l L I TIES. IND/CATES INDICATES
PERt�AT I AN _ 09 OVED--
6. VERTICAL DATUM /S:
u TP* Tpir
LEGEND
GRND EL. O .O GRND,EL
oar i
�• �� Q. W.EL. 0. W. L.
50_ — EXISTING CONTOUR P P �:., LOT 8 �� � , , �
�-- ti _ _ r..0 _ PROPOSED CONT01lR q svmo t
43562- .F. 50X0 PROPOSED SPOT 6NAIJE
w. L,P. , 10g �.,....... DIRECTION OF GROUND ;YATER 5 uv F
RUNOFF
mdo h ♦ ► -' 5
{ .._ &
AA Yi s}*i
i
c v
n
DATE:
TEST BY.-
WITNESSED BY: � •TAGC)'Fj I
J � �II�
.P �� W L✓ \�� 4 DAK . - . PERC. RATE: '�' 2 MI NY INCH
ILO
00
O N as
Za zit
O Ln
R ER;
Au MftC�H 31E4N)cz 7(y
V�J 0,
,/ ',• y /
A � 0
LQ
Pff" OAK
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VIL
12
ro
`- PLAN SHOW NG THE DESIGN OF A PROPOSED
SUBSURFACE SEPTIC DISPOSA
Z?5'; o�� ' 96X34 `
LOT 8 CARS ��� . L ON LAND; f�ARNSTABLE; �9A)
98_ SCALE .� " kv
D ' JUL Y .1. 1992
O� EAGLE SURVEY NG i ENGINEERING, INC.
wtLL- g i�P'S1�G MAS'T�P, 1'A�.I'-�� ,
441 ROUTE" .130, SANDWICfa IVA
PROLAECT NUMBER 92-077
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j
DES/ GN CR I TER/A : INVERT ELEVATIONS:
GENERAL NOTES; DESIGN FLOW: INVERT AT BUILDING; 1o2.0U
I . THIS PLAN /S FOR THE DESIGN AND C1U of Fp►JNT�t�'tlpts BEDROOMS AT ISO G. P. D. PER INVERT /N SEPTIIC TANK; �� 1 '
{ 06. �TaP ACCESS COVERS MUST BEDROOM EOUAL S G. P. D INVERT OUT SEPTIC TANK: !O 1 . 55
CONSTRUCTION OF THE SEWAGE DISPOSAL o 'O FIRST 2' To
BE WITHIN 12 OF
FACILITY ONLY. BE LEVEL FINISH GRADE LQ GARBAGE GRINDER INVERT IN DIST. BOX: l00.35
INVERT OUT D 1 S . BOX: 10 0� 18
4 ' PVC MIN: 2` OF � e
CEPT I C TANK REOUI RED: �9 (y�
2. ALL CONSTRUCTION METHODS AND SCHEDULE 40 0 �r PEASTONE INVERT 1N LEAC PI T:
10�►00 15p0 101.55 . _ 4 p G. P. D. X 150X = GO GAL. 013,00
MATERIALS FOR THE SEPTIC SYSTEM GAL• Iab ,1 � ' .o� 3v4 ll/2 -- BOTTOM OF LEAC PIT:
10 1' SEPTIC TANK W DIA. WASHED SEPTIC TANK PROVIDED._ GAL. I ;
SHALL CONFORM TO MASS. D. E. P. OUTLET 93 vrp STONE ADJUSTED GROUN, WATER.
TITLE 5 AND LOCAL BOARD OF HEALTH l o' MIN. H-10 D-Box a.► OBSERVED GROUND WA TER: NON
6 , a ,. tiE OF LEACHING FACILITY
REGULATIONS. LEACH PITS Rc-OU/RED; 440 G. P. D.
3. ALL SEPTIC SYSTEM COMPONENTS LOCATED PROFILE; NOT TO SCAL r 44-20 DF-SIGN PERC RATE _�— MIW INCH
REVISIONS;
UNDER PAVEMENT SHALL BE DESIGNED TO H -zo 1� •BK1f1l)
PROVIDED: Z 6 'PIT(S) W/ 3 'STN. NO. DATE REVISION
WITHSTAND H-20 LOADING. 1ofspf-RTNAU 3 F"V•
SIDEWALL: y52 S. F. X 0 GPD
4. ALL SEWER PIPE SHALL BE SCHEDULE 40 BOTTOM., 7-Z-� S. F. X l'� � = 2�.G� GPO
TOTAL: G7 S. F. 135G GPO
OR APPROVED EOUAL . SO1 L. B�ASi�Ar`fH LtiA�G� p1`(S
1H1,S•'r �� VT�R1 Pl'Eb ,4`c'
5. BEFORE CONSTRUCTION CALL DIG-SAFE or- Co"STRUC'510m. SOIL TEST PIT A TA
1-800-322-4844 FOR LOCATION OF i
1AVICATES 1ND CA TES
PERCOLAT I AN
UNDERGROUND UTILITIES. _ OBSERVED-
�_
� 6. VERTICAL DATUM IS: �c SS VM�� _ � ��-_�'s�"�-=-- GRO�+IDw�tTER
I;
L EGEND GRND EL. O GRNa EL
N G. K EL. Po" G. W.FL. .R
EXISTING CONTOUR
iris V L.P• Q IY� �+ ,
LOT 6 _ _ I;5o1 ___ PROPOSEO CONTOUR sveso�t
/ p 4
4356,?4 .F. oOXO • PROPOSED SPOT GRADE
"' •P 108 - DIRECTION OF GROUND WA TER y,� �
w _
RUNOFF l
o h �Fi�ES
l
0
.;
�> w �.P• m � I
�.3 ►^� o .`. . DA T E; 3/7 1
L LTEST BY:
Do�Le ASSOC
W I TNESS,--o B Y., 7. 3A 60
n i CS
24 SOAK , J PERC. RA TE: '�' 2- M 1 N/INCH
L P O �? ti✓ 7x
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h �. e e� CZ ti`�b� Q 0 Eti hdo. 24 C N
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0 / 0 .^ .,c CIVIL I Q t
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1` qo L14 yi. °ai��,ONAL
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N �� gip, r� Li
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24'' OAK
WWI
N r3 0 m W
PL AN SHOWING THE DESIGN OF .A PROPOSED
oa SUBSURFACE SEPTIC DISPOSAL SYSTEM/
Z,s o�, ' 96X34 LOT g CARL SON LANE,, BARNSTABL E MBA
9B98- �,
SCALE J 40 JUL Y 13 •1992
EAGLE SURVEYING G ENGINEERING, INC.
dd1 ROUTE 130, SANDWICH,, MIA
wtl.L— SZP TS C. MAST-P, 'PLAN \` PROJECT NUMBER 92-•077
'I