HomeMy WebLinkAbout0111 CEDAR STREET - Health cedar Street
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TOWN OF BARNSTABLE
LOCATION /// G'�dA� 5/44 SEWAGE #
VILLAGE /3�9�/1SL,�L�G ASSESSOR'S MAP & LOT13 " 03
i INSTALLER'S NAME&PHONE NO. 0-41-,Zvn1, Ze- ✓S
SEPTIC TANK CAPACITY 5e 'L k
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: 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
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form rJI
I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street ,
L. Property Address
Heather Sherman
Owner Owner's Name 1,
information is P7
required for every West Barnstable Ma 02668 9-6-18
r',•7
page. City/Town State Zip Code Date of Inspection r
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
�s Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
� .. Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey ^ " ���� . .�� 9-06-18
�pate:2ptB.09.A 12:02:ffi 040P
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
5
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
J4
9 P Y rY
111 Cedar Street
L
Property Address
Heather Sherman
Owner Owners Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑Q 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:
The system was in working order at the time of inspection but the leach pit has been stained to the top off the
effective leaching area. A high stain line was observed at the top row of leaching holes in the leach pit.
SAS was dry when viewed at time of inspection"
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
cam, Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
V
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Heather Sherman
Owner Owners Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ O Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/z day flow
❑ a 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.
❑ O Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with.no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ Q The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No .
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�e ,lp Title 5 Official Inspection Form
�a1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
v
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ 0 Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ O Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ Q Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
Q ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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?
❑ a 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:
El ❑ Existing information. For example, a plan at the Board of Health.
Q ❑ 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
�v
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 3
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/gpd
Description:
1
Number of current residents:
Does residence have a garbage grinder? ❑ Yes 0 No
Does residence have a water treatment unit? ❑ Yes 0 No
If yds, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes F!] No
Seasonal use? ❑ Yes [E No
NA
Water meter readings; if available(last 2 years usage (gpd)):
Detail:
***WELL WATER***
Sump pump? ❑ Yes W No
current
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
gal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
v
Property Address
Heather Sherman
Owner Owner's Name
information is west Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Heather Sherman
Owner Owner's Name
information is west Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Permit dated 6/29/1990
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑ other(explain):
>100' from well to SAS
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
c Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
........... 111 Cedar Street
V
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
2'
Depth below grade: feet
Material of construction:
■❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
611
Sludge depth:
3011
Distance from top of sludge to bottom of outlet tee or baffle
211
Scum thickness
619
Distance from top of scum to top of outlet tee or baffle
14If
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
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 in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
_
Depth below grade: NAfeet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm,present: ❑ Yes ❑ No
Alarm Revel: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Bnx(if present must be opened) (locate on site plan):
0'r
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
l5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
AN,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ia1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Heather Sherman
Owner Owners Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
(1)6'x6' pit
Q leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: -
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
,e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e 111 Cedar Street
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.}.
The leaching was in working order at the time of inspection but has been stained to top of effective leaching area.
Pit was empty at the time of inspection.
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
NA
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.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
�v
Property Address
Heather Sherman .
Owner Owners Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
V�
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
■❑ hand-sketch in the area below
❑ drawing attached separately
Asbuilt Ground Water
I
3'
0 0 0 6'
Q 0 0 0
20'
B Front of house 0 0 0
0 0 0
A1.14' 81.26'
A2.17' 82.19'
3 A3.43'8" B3.24'
>11'
0
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
V
Property Address
Heather Sherman
Owner Owner's Name
information is west Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
0 Check Slope
Surface water
0 Check cellar
0 Shallow wells
>20'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
0 Observed site (abutting property/observation hole within 150 feet of SAS)
n Checked with local Board of Health -explain:
A previous inspection report was also reviewed
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
An abutting property has a large drop of>20' showing high ground water is greater
than 10' below the bottom of the SAS. A previous inspection report was also viewed
were town maps and charts showed it was greater than 20' to ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
�e p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Heather Sherman
Owner Owner's Name
information is West Barnstable Ma 02668 9-6-18
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 3, or checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
■❑ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
r:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
p ��%
Subsurface Sewage Disposal System Form Not for Voluntary Assessments � �`
'GSM 111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23, 2014
page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David B. Mason
use the return Name of Inspector
key.
David Mason
Company
Name
4 Glacier Path
Company Address
r East Sandwich MA 02537
City/Town State Zip Code
508-367-1617 S1287
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 onzsi:te
sewage disposal systems. I am a DEP approved system inspector pursuant to"Section15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
June 24, 2014
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•3113 Title 5 Official Ins cVF.. ubsurface Sewage Disposal System•Page 1 of 17
~� Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is West Barnstable MA 02668 June 23 2014
required for every ,
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The observations noted in this report represent the condition of the system only on this date of
inspection and the information contained herein does not guarantee the continued operation of the
system. It should be noted that there are indications of staining below the effective leaching area in
the leaching pit as viewed on camera. Staining is an indication of effluent holding over a lengthly
period of time which is associated with possible hydraulic faiiure, but at the time of inspection the
system as inspected did not meet the failure criteria.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is West Barnstable MA 02668 June 23 2014
required for every ,
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y. ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑. ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety'and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
II
Commonwealth of Massachusetts
L r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is West Barnstable MA 02668 June 23 2014
required for every ,
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 '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 111 Cedar Street
Property Address
Peter SamP ou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23, 2014
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 coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system,is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth cf Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is West Barnstable MA 02668 June 23 2014
required for every ,
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM , 111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d No
9 ( Y 9 (gp ))�
Detail:
Dwelling is serviced by a private well this no water use records available. Well is 54 feet
perpendicularly from the right rear conrner of the house to the right of the house. Leaching is 100 feet
from well head based on camera location of leach pit.
Sump pump. ❑ Yes ® No
Last date of occupancy: 6 months
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•3/43 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
111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Board of Health
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23, 2014
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:
20 years according to owner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 34"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Observable components appear adequate.
Septic Tank(locate on site plan):
Depth below grade: 20"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallon typical
Sludge depth:
3"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23, 2014
page. CitylTown 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
42"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Scour Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Precast baffles in place. Effluent level with 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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
111 Cedar Street
Property Address '
Peter Sampou
Owner Owner's Name
information is West Barnstable MA 02668 June 23 2014
required for every ,
page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23, 2014
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 Level with outlet invert.
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box is 40 inches below grade with riser. Evidence of solids carryover and staining in dbox
but at time of inspectin the effluent was level with outlet tees. Indication of past backup but at time of
inspection meets passing requirements.
Pump Chamber(locate on site plan):
Pumps-in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working orders stem i P P g y s a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Located SAS with camera. Exact location unknown.
l5ins•3/13 Title 5 Official Inspection Form: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
111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is West Barnstable MA 02668 June 23 2014
required for every ,
page. Citylrown 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/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
With use of camera, observed staining in the leaching pit below the invert/effective leaching area.,
but at time of inspection only 1 foot of effluent in the pit.
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 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
111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins-3113 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
,M •'' 111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23, 2014
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
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:
Town groundwater contour map
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized Town of Barnstable Groundwater Contour Map
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
111 Cedar Street
Property Address
Peter Sampou
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 23, 2014
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.17 of 17
Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTA13LE �3
LOCATION SEWAGE#
VILLAGE ,6Z1, ASSESSOR'S MAP&LOTISO
INSTALLER'S NAME&PHONE NO. 1.ik:Zn g i A",i fS
SEPTIC TANK CAPACITY /Cr u lr
LEACHING FACILITY:(type) /P/Jr �/>- 'l (size)
NO.01i,BEDROOMS
BUILDER OR OWNER G 2 �27w.1
PERMITDATE: DATE:_S//—?A)-Z.
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
l°I
!DPP_,_]
g
�41
I
0
/F'r OWrer �Ddd G.` I-¢1C4:-1 lair
J
t III
t I
http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=130031&seq=1 6/26/2014
COMMONWEALTH OF MMSACHUSETTS RECEIVED
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r d DEPARTMENT OF ENVIRONMENTAL PRIOTRilb& 2002
TOWN OF BARNSTABLE
HEALTH DEPT.
9,N 5.0
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: I I I Cedar Street W.Barnstable
Owner's Name: George Thew
Owner's Address:
Date of Inspection:9/13/02
Name of Inspector: Timothy Lovell
Company Name:Accurate Inspections MAP
Mailing Address:550 Willow Street PARCEL ; U
W.Yarmouth,MA. --- �
Telephone Number:508-771-3700 LOT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_X_Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 9/13/02
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
i t '
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 111 Cedar Street W.Barnstable
Owner: George Thew
Date of Inspection: 9/13/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_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:
_N/A 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.
_N/A 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 infiltration 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:
_N/A 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:
N/A_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: 111 Cedar Street W.Barnstable
Owner: George Thew
Date of Inspection: 9113/02
C. Further Evaluation is Required by the Board of Health:
_N/A 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:
_N/A_Cesspool or privy is within 50 feet of surface water
N/A_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:
_n/a_ 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.
_n/a The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_n/a_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
n/a_ 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:
F
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Ill Cedar Street W.Barnstable
Owner: George Thew
Date of Inspection: 9/13/02
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'/z 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 form.]
No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CUR 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: N/A
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 H 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: 111 Cedar Street W.Barnstable
Owner: George Thew
Date of Inspection: 9113/02
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?
_n/a _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 bales 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) 1310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 111 Cedar Street W.Barnstable
Owner: George Thew
Date of Inspection: 9/13/02
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):_n/a
Seasonal use: (yes or no):
Water meter readings,if available(last 2 years usage(gpd):
Sump pump(yes or no):_no_
Last date of occupancy:_Current
COMMERCIAL/1NDUSTRI4,L n/a
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
Source of information: owner 2001
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:
Kennedy installed new system in 1990 owner has bill showing payment and what was installed
Were sewage odors detected when arriving at the site(yes or no):_no_
r
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 111 Cedar Street W.Barnstable
Owner:George Thew
Date of Inspection: 9/13/02
BUII.DING SEWER(locate on site plan)
Depth below grade:_2'
Materials of construction:_cast iron _x_40 PVC other(explain):
Distance from private water supply well or suction line:_50+
Comments(on condition of joints,venting,evidence of leakage,etc.):
Piping looks fine no evidence of leakage joint seem tight venting ok
SEPTIC TANK:_z (locate on site plan)
Depth below grade:_4"
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: 1500 Gallon Tank
Sludge depth:
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:_6"
Distance from bottom of scum to bottom of outlet tee or baffle:_14"
How were dimensions determined: in the field tape 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 looks to be in good shape,liquid level at invert out,tees in place covers built up with in 4"of finish grade,
No evidence of leakage,
GREASE TRAP:_n/a_(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.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ill Cedar Street W.Barnstable
Owner: George Thew
Date of Inspection: 9/13/02
TIGHT or HOLDING TANK:_n/a (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: X (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.):
Bill did not indicate distribution box installed I snaked line from tank out and found D box cover 3'4"deep,box in
good shape liquid at invert out no evidence of solid carry over
PUMP CHAMBER: n/a (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.):
i
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 111 Cedar Street W.Barnstable
Owner: George Thew
Date of Inspection: 9/13/02
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Could not locate 1000 gallon leaching pit the Bill said he put in cover could be deems because of sloped propertyIdid
snake line from D box but ran into bends I did probe and found nothing
Type
_x_Leaching pits,number:—I—
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.):
According to Bill owner has Kennedy put in a 1000 gallon leaching pit with 4' of stone
CESSPOOLS:_N/A (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:_n/a (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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 111 Cedar Street W.Barnstable
Owner: George Thew
Date of Inspection: 9/13/02
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.
>y�
Front of Home
Drive way
Approximately the location if of leaching pit
I �,
' Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 111 Cedar Street W.Barnstable
Owner: George Thew
Date of Inspection: 9/13/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+_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:
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)
X_Accessed USGS database-explain:date 2
You must describe how you established the high ground water elevation:
Information Provided by Cape Cod Commission Map plate 2 well index data Well#SDW-252 August 15 report
indicates ground water at 47.9 with Zone B adjustment of 3.0 water table at 44.9 ft approximate separation between
bottom of leaching pit and ground water 25'
r�
p4 4
No,.4, .F..� Fics....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tons' ilan rrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
.....��/_.�.. �-,/S1 ._... ✓ - --•------•------------------------•-------- -----------------------------------------
-•• - . -
cation-Address or Lot No.
.... ... .........%... — ..30
..-----
. .
a ( ' ......... - .n .... ......................... ...S25-._...-.. - .'.n ...----
nstaller Address
e of Building Size Lot............................Sq. feet
U Dwelling—No. o Bedrooms__....__6.................... .Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
POther fixtures -----•------------------------------------------------------------------------------------------------.....••-•••-•--••-•----•-------•-------•---•-•-.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity......_.....gallons Length................ Width................ Diameter-----------_.... Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet...................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed'by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2----------------minutes per inch Depth of Test Pit-----------------_.. Depth to ground water.-__-_---..-___----____-
---•-------------------------------------•----------------------•-........--••--•----•-•------------.........................................................
0 Description of Soil........................................................................................................................................................................
x
�.,
W ---••---•-•------------------•---••------••-----•••-•-•--••----•----•---.....................................= -----••= ,
UNature of epairs o Alterations—Answ applicable -_._ Q . ......._.
--------------Aw--_& .-••••.... - �' -- ---••--------(f'-------- ..........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia has been 'ss d by t e board of health.
Signed ....... .. . ... ..... . .. . . --... -------------- ---------..... --- --------------
,r� ' Date
-
Application Approved B ----- yam` ----.. .. ".. - 3"' lf
`---... .-----'- --- -- ------------------------------------_-.....----.....--'- ------------- .....----Dace
Application Disapproved for the following reasons- -------------- ------------ ------ ---- ................ .............................................................
---------------------------=----------------------------------------------------------------- . . ------........------------------------
Dace
Permit No. ". *� :............ Issued � . .. ......` ............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH.
TOWN OF BARNSTABLE
Tez#if rate of Tont}altttxue
THIS IS TO CERT FY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....................�--�......-Q................... w ...e f .....------------------.....In--stall----er-....................................................--------------------------------...-----------------------------
has been installed in accordance with the provisions of TITLE 5 'f T e� ate nvi onmental Code as described in
the application for Disposal Works_Construction Permit No. '.:.: .t...e .�. ..... dated --- : :_� ''_. +D
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR AS A GUAR T E THAT THE
SYSTEM WILL FUN TION SATISFACTORY.
DATE�'� �� Inspector ........................----- �,
4
V
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH a
TOWN OF BARNSTABLE
Appliration for Uiipntia1 Workii Tianitrurt"Wit Fautit "
Application is hereby made for a Permit to Construct ( ) or Repair ( 7an Individual Sewage Disposal
System at:
.....�!.�_. .� �...:.• . ............ ..��-..�� '.� ..............................................................................•....•..............
ation-Address or Lot No.
-- _r! %�-ri..... ........................•..... .........._................................................................Add ......•...._
y s14
.. ...
....
v aller 1/ Address
PQ
S feet
� e of Building Size Lot___________________________ q.
Dwelling—No. of Bedrooms___...s_5--------------------------------Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building ............................ No. of persons_...__-__-__-__-____-------- Showers ( ) — Cafeteria ( )
Q' Other fixtures -....................................................................................................................
W Design Flow............................................gallons per person per day. Total daily flow..............................................gallons.
WSeptic Tank—Liquid capacity............gallons - Length_______________ Width------- ......... Diameter................ Depth................
Disposal Trench—No.--------------------- Width.................... Total'-Length................ Total leaching area...................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1..:.............minutes per inch Depth of Test Pit.................... Depth to ground water--_____--_______...___-.
Gz., Test Pit No. 2----.--_------_minutes per inch Depth of Test Pit____________________ Depth to ground water.........................
a .......--------------------------------------------------------------------•------•----....-----------.................:.......................................
0 Description of Soil....................................................................................................................................................................... ._
x
U ----•------------ - --------
W . ...................•........ ----••-••-•-----•••---•--•------------•---•••••---•••----------------•---------- .. -- ......
V Nature of Repairs or Alterations—Answer when applicable__-_ _... 11,E-._,�/ ___. . ._. _.__.___... ......__.
- . •---
"Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal_System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in'operation until�a Certificate of Compliance has been issued by t e board of health.
rl Signed ..------- / -�--I�--- ---- ------------
-------------------- -------------
Dare
Application Approved Bye.-------- - � .......�� ( ................................../ -------- '----'--�----- '�.......-�- �lS
---- ----- ----
. Dre
Application Disapproved for the following reasons- -----------------------------------
--------------------- - - --- - - ----------------------------------------------------------------------------------------------------------------------------------------------- ........................................
✓� �//{ /J,�,�r.�`
1 D -.Ekt... Y Mare
Permit No. Issued - -- -----9
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cnez#tftra#e of (ILTIImpliance
THIS IS TO CERT Y, That the Individual Sewage Disposal System constructed O or Repaired ( )
by ---------------------ZI.e". /. f� �
------------------------------------------------- ---:--- -------------------------------------------------------
Insraller - !
e
at -'---...------t/o----------� .A.... 1, ...... � ►v /-. l,I ;'------------------�`--`'.....
has been installed in accordance with the provisions of TITLE 5 of The State Znvir onmental Code as described in
the application for Disposal Works Construction Permit No. .....�4`....r' . M✓��.. dated ......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED/AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ( A I/--GII ------------ ll Inspector .... - C�
_ ...
, �
THE
f
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
y TOWN OF BARNSTABLE
N o......./..�..............
FEE:.
�i��r�a��,1--� �rk�
Permission is hereby granted--------- `�J_ ✓' -/ ' `-'.....---••---------------------------------------------------•---••---....
to Construct�( ) or�Repair ( t.-)'an Individual Sewage Disposal System
atNo---=----------/•...! .cy .......... ..................................................
Street .� �
as shown on the application for Disposal Works Construction Permf�t,`No.........r ....... ..... Dated.�.f �_.
..... ............_......C-...... ,
�� �� �� Board of Health
DATE........ .............................
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS /
I
Fee— -- ---------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applitation-*rVell Congtructionperntit
Application is hereb made or a permit to'Construct (+Ater ( ), or Repair ( )an individual Well at:
— 11 -1�_---0), rear�--- ----------------------------------------- -------- --- ---------------=----------
Location — Address Assessors Map and Parcel
-------- }
p Address
r�_►_1_i�► ----------------- �- Q- � _,__ � 1-1 ---c .5
Installer — Driller A dress
.� Type of Building
DwellingL � -
Other - Type of Building--------- ------------------ No. of Persons-----------------------------------------------
„ --------------- Capacity
�` Type of Well---- ---:---��I-------------------------- --------------------------------------------------------------------------
------
Purpose of ______________
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 Co pliance has been issued by the Board of Health.
Signed- = _'= _
dat
Application Approved By
at€
Application Disapproved for the following reasons:--------------------------- - — — — — --------
------------------------ --------------------- ---------------------------------------------- ------ --------------------------------------------
date
Permit No.--- ------- ------------------------ Issued--------- ----�---!------------------- -
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f COMPhancr
THIS IS TO CERTIFY, That the Individual Well Constr ted Altered ( ), or Repaired ( )
by---------- �%/J 1A -—� — ------------------—--- ___- — - - - -----------
Installer
a t---------------- 11 — - — - ___has been installed in accordance with the provisions of the Town of Barnstable Board of Healt�Private Well Protection
Regulation as described in the application for Well Construction Permit No.W�� , -Dated-----------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------------------------------------------
------------------------------ Inspector—-------------------------------------------------------------------------
i
No.--------z--- ------- -------------ee �
BOARD OF HEALTH
TOWN OF BARNSTABLE ;
0pplication forlVell Cootructiort3permit
Application is hereby for or a permit to Construct (✓), Alter ( ), or Repair ( )an individual Well at:
i * t
fw
Location — Address Assessors Map and Parcel
1
76
� c -4�0r� e e.L�— — --------------------— �4— = =
Owner Address
S_ '�P, 1_2 U o �c��is k VIIA Oa506
Installer — Driller U Address
Type of Building - '
Dwelling \Y1 ' ----------
Other - Type of Building ' �_ _:-_____ : No. of.Persons----- _ ----------------------
Type of Well �F �U-)f-I — —— ------- Capacity- -- — _—
Purpose of Well- - j��K���� --
Agreement: V
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 Co pliance has been issued by the Board of Health.
Signed $ !
dat
Application.Approved By--
ate
Application Disapproved for the following reasons:
— date
Permit No.---------------_------- ------------ Issued------------ ----�---date 1 ----
BOARD .OF HEALTH
" TOWN OF BARNSTABLE
C ertif icate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Conrytructegd (' ),, Altered ( ), or Repaired ( )
by------— --- --------Lt_!v���(�,I/1---- �l .Q .w 1Ll --11 k l!1 !__ - - - — ----- - —------
Installer
►� e d � o lt�• Vrin
at------------�-----------__��--�--_____ _ �Q�l�____----------------
has been installed in accordance with the provisions of the Town of Barnstable Board
He It�nPrivate Well Protection
Regulation as described in the application for Well Construction Permit No.L--!� !�!Dated-----=-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -------—- - — ---__ —__ Inspector—--- - __- —---- —
BOARD OF HEALTH
TOWN OV BARNSTABLE"
)Vrll Congtruct ion Permit
- � _ _
No. �-- _. Fee --�------
Permission is/hereby granted
to Construct ( ), Alter ( ), or Re air ( ) an Individual Well at: L
No. -- -- — - 1_t_ IJ f ----�'l lee -1 --- =----- CS!n s-C CL(n Pr- - - — -
Street
as sh(own�(o rthe application-for a Well Construction Permit
No.1% -/! /�! . ------- - ---__ Dated --ld
--- q / —
Board of Health`s
DATE - � � /// -------
FeF d ---
-----
e-- ---------
BOARD OF HEALTH
TOWN OF BARNSTABLE
zlpplication_*r3Vell Con5truct ion Permit
Application is hereby made fo a e it to Zc Alter J�), or Repair ( )an individual Well at:
- � -------------------—----------------------------------------------------
L c iln — - -
— Address Assessors Map and Parcel
tp , ---------------- -0- ---------------------------------------------------------------------------------------
Owner Address
- - - -JOB P �---------------------------------------
Installer — Driller Address
Type of Building
01welling---------- -----------------------------------------------
Other - Type of Building ----------- No. of Persons--------------------------------------------------------
Typeof Well--------,I m`-'"L_C --------------------------- Capacity------------------------------------------------------------------------------
Purpose of Well_ --------------- ------
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 un a Certificate of Co 1' ce has been issued by the Board of Health.
Signed— - --------- --•------1 - - -' ='
date
Application Approved By - - �� —. -- - - -------- —- --- -
date
Application Disapproved for the following reasons:-------------------------------------------
--- ---------------------------------------- ---------------------------------
date
Permit No. --—- - --------------------- Issued -------------- -- - - --- -
ate
BOARD OF HEALTH
TOWN OF BARNSTAB LE
Certificate Of Compliance
THIS IS TIFY, That th ndi idual Well Constructed ( ), Altered ( ), or Repaired ( )
by----- - - -- -------- — - ��IL__�__----------- AI
t ---------- ----- .-------------------------------------------------
-------------------------
has been installed in accordance with the provisions of the Town of Barnstable Boar ealt ivate Well Protection
i
Regulation as described in the application for Well Construction Permit No. - --- --- ated------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
- ---------- Inspector-- — -- --- -- - -- - ------------
DATE---------------------------- -
No.--r�------ ------ Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
Zipprication for Melt Cootructionpermit
Applicatiron is hereby made for a,pe;. it to opstrukk
Alter 00, or Repair ( )an individual Well at:
y - -
6r_t ,
Ldcation — Address " Assessors Map and=Parcel :=
��_e 8 P 9.. _- 2 ct�—--- --------—
_ Owner Address
------
Installer — Driller Address
Type of Building
wellin' ,
1l g ------- -- - - - -
Other ,,,Type of Building--------------------------------I No. of
Type of Well---- .�) ( -- - -- Capacity-----------------------
Purpose of Well ----------------------
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 Comp41nce has been issued by the Board of Health.
Signed
date
Application Approved By-- n - - ---- -- =' --�
date
Application Disapproved for the following reasons:-----------------------_______________:
-- W t � — date
Permit No. --_ -- �=- - - - - -- Issued- - - -'..�, - -- --_—_—
date ,
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f Compliance
THIS IS TO-C RTIFY, That the'-Individual Well Constructed ( ), Altered ( ), or Repaired ( )
by—- -_ - 111�11 - -- -- ------------- - p-------------------------------------------------
/'
at
has been installed in accordance with the provisions of the Town of Barnstable Boar HeaMated
vate Well Protection
Regulation as described in the application for Well Construction Permit No. ---� ,- -------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE-CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------------------------------------------------------------------------- Inspector---------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Veer (footructionA3ermit
IV No. o Fee--- ---------5------i
a.
�
Permission is hereby granted - �)- - -
I YII__!j__; ----------------------------------------------------
to Construct ( Alter ( or Repair-(\ an Individual W, All a't'No.
___ ___--
' Street
as shown o �the applic�ati)on/ for a Well Construction Permit
No.-- lI�v---t' —__ -—--_—___ Dated- > --� — ----- -,
•Board of Healthk,
DATE--- �v ��
1
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