HomeMy WebLinkAbout0515 CEDAR STREET - Health L
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BORTOLOTTI CONSTRUCTION, INC.
45 INDUSTRY ROAD, MARSTONS MILLS, MA 02648 m o
508-771-9399 508-428-8926 FAX: 508-428-9399 �.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: J
Date Of Inspection q. /7 Inspector's Name:
OwtyRr's Name and Address:
A119 �c7LD(D
CERTIFICATION STATEMENT:
I Certify that I have personally Inspected the Sewage Disposal System at this address and that.the infornia-.
tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform-
ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis-
posal Systems.TI 'system: ,
Passes
Conditiona sses
Needs Furtl Eval a o By the Local Approving Authority
Failu
Inspector's Signature Date:
The System Inspector shall subm' a copy of this Inspection Report to the Approving Authority with Thirty
(30) Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd
or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Office of
the Department 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:
A) SYST PASSES:
I have not found any Information which indicates that the System violates any of the fail-
ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi-
cated 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,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not
determined",explain why not.
The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil-
tration,or Tank Failure is imminent. Tile System will Pass Inspection if Existing Septic Tank
is Replaced with a conforming Septic Tank as Approved by the Board Of Health.
Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to
broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. Tile System
will pass Inspection if(With Approval of the Board Of Health):
_ 1 _
F
SUBSURFACE SEWAGE-DISPOSAL,SYSTEM INSPECTION FORM
PART- A
CERTIFICATION (continued)
Broken pipe(s)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 1S REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board Of health in order to determine it'
the System is failing to protect the Public Health,Safety and the Environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HELAT'H DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING 1N A MANNER WHICH WILL PROTECT"1'HE
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 OFxHEALTHi(AND PUBLIC WATER
SUPPLIER,.IF APPROPRIATE)DETERMINES THAT THE SYSTEM_,IS FUNCTION-
ING IN.A MANNER THAT PROTECTS THE PUBLIC HEALTH'AND S'A'FETY.AND'1'HF,
�.ENVIRONMENT:
The system has a Septic Tank and Soil Absorption System and is within 100 Feet to a S�irface
Water,Supply or Tributary to a Surface Water Supply: `
The System has a Septic Tank and Soil Absorption System and is with 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 and volatile organic compounds indicates that the Well is from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
1 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 into facility or system component due to an overload 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 i
S tatic1iquid-level in the distribution box above outlet nNert due'`to a►i overloaded or clog-
.
gedSAS or.cesspooL,,
. , :Liquid depth in cesspool ks jess than G;'below invert or available Viihime is less than 1/2
day flow.
Required pumping more,than;4 tines in the last year NOT due'to clogged or obstructed
pipe(s). Number of times pumped
- 2
Y
1.
' SI113SUIiFACN SF,WAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
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 a large system in addition to the criteria above:
The.design now of a system is 10,000 ggd 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
y 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 11 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 315 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the fo lowing have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
✓None of the system components have been pumped for atleast two weeks and the system has
been receiving normal Clow rates during that period. Large volumes of water have not Been
introduced into the system recently or as part of this inspection.
As-built plans have been obtained and examined. Note if they are not available with N/A.
✓
The facility or dwelling was inspected for signs of sewage back-up.
_�`fhe system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.-
All system components;excluding the Soil Absorption System,have been located on site.
{ . The septic.tank manholes were uncovered,opened;`'and the interior of the septic tank was in-
spected for'condition of baffles or tees;`mateeial oUconstruction,dimensions,depth of liquid,
depth of sludge,depth of scum.
V The size and location of the Soil Absorption System un the site has been determined based on
existing information or approximated by non-intrusive methods.
- 3 -
wi�tSr�:�3•s ra`.j�r+ ?i�+ L`S'�sKt zi-�fy�j�r.
SUBSURFACE SEWAGE DISPOSAL SYSTEM ,LNSPECTION FORM
PART B
CHECKLIST(continued)
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C:
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow% M gallons Number of Bedrooms:_Number of Current Residents:
Garbage Grinder:_ Laundry Connected To System: (/wela Seasonal Use:,,,,�)--
Water Meter Readings,if available:
Last Date of Occupancy —
_COMMERCIALANDUSTRIIAL:
'• T e'of Establishnienf:
Yp
Design..Flow: ... gallons/day"Grease'frap Present:'(yes or
Industrial Waste Holding Tank Present:. _.
Non-Sanitary Waste Discharged To The Title V System: ,
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: (Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS any source of information:
System Pumped as part of inspection:_ I yes,vohdne pumped: gallons
Reason for Pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If y ,attach previous inspection records,if any) _
✓ Other(explain): Va2 _s', 1(J� �
A.PPROXIMATE.AGE of all components,date installed (if known)and source'of information: ' y
Sewag odors detected when arriving at the site: - -
-4-
'SUBSURFACE SEWAGE DLSI'OSAL'SYSTEM INSPECTION FORM
PART C
GENERAL INF011MATION (continued)
SEPTIC'TANK:
Depth below grade: Material of Construction: f concrete o►►etnl FRl' Other
(explain)
Dimensions: ' Sludge Depth: 7,411
� ��n'Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: y"
Comments: (recommendation for pumping,conditioin of inlet and outlet tees or baffles,depth of liquid)evel
in relation to on invert,structural iutegrit ,e idence of leaka ,etc.)
u
GREASE TRAP
Depth Below Grade: Material of Construction: concrete-metal-Flip Other
(explain):
Dimensions: Scum'Thickness:
Distance from top of scum to top of outlet tee or baffle:
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.)
TIGHT OR HOLDING TANK
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain):
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX ''
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or
out of box,etc.)
PUMP'CHAMBER..
Pmiip is iii..working'order -
Comments:(note condition of pump chamber,condition of pumps and appurtenances,etc.)-
5
x SUBSURFACE:SEWAGE DISPOSAL SYS'I'IP.M, IN:SPEC11ON NORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS): V
(Locate on site plan,if possible;excavation not required,but may be approximately by non-intrusive
methods) .If not determined to be present,explains
Type:
Leaching pits,number:_ Leaching chambers,number: Leaching galleries,number:
Leacahing trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Co invents: (note conidtion of soil,si ns o hydraulic failure level of onding,col dition pf egetation,etc.)_
CESSPOOI,S:Z&—
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(cesspool must be pumped as part of inspection)
Continents: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
h Depth of Solids:
Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation,
etc.)
y .
„`s. 1. .. ...... .. ..,._ " .
6 -
SUBSURFACE 'SEWAGE-DISPOSAL' SYSTEM INSPECTION FORM
I'ART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references,landmarks or benchmarks.
Locate all wells within 100 Feet.
� l
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet
Method of Determination or Appr ulna 'on: � ✓
1id° �' d e c!I"
u
- 7
ep 16 1411,22p p.1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes _
Owner Owner's Name
information is West Barnstable MA 02668 9-16-14
required for every ..
page. CityfTown 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.
I out
f:When A. General Information
fillingMing out forms tttutntlupfq��
on the computer, y��Q� ����� ZN OF M,qS 1z
v 1� V V `✓ •.�9 use only the tab 1. Inspector: .`�'��`�'•
key to move your , y
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c _G
cursor-do not _ JA
James D.Sears _ 3�: MES
use the return :m
key. Name of Inspector ^v
CapewideEnterprises,LLC �•. o a *=
s�I Company NameNTI
153 Commercial Street gi�i��F rS IN S'ev c
Company Address
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I 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
9-16-14
spector'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.
q
15ins•3113 Title 5 official Inspection F surface Sewage Disposal System•Page 1 of 17
i
Sep 16 14 11:22p p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Cedar Street
Property Address -
Lori Barnes
Owner Owner's Name
information is
required for every West Bamstable MA 02668 _ 9-16-14
page. Cityf town State Zip Code Date of lnspeation
B. Certification (coat.)
Inspection Summary: Check A,B,C,D or E l 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 system is a 1000 Gal.Tank and Pit.
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 meta] 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):
!Sins-3113 TWO 5 Official hcpocoon Form;Subsurfeco Sowago Dlsposel Gyatem.Page 2 of 17
Sep 161411:23p p.3
Commonwealth of Massachusetts
Inspection Form
Title 5 Official Ins
- p
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owner's Name
information is required for every West Barnstable MA 02668 9-16-14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpstalarms are repaired.
13) System Conditionally Passes(cost.):
❑ 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
l5ins-3113 Title 5 ofllcal Ins peolion Form:Subsurface Sewage Disposal System-Page 3 of 17
Sep 16 1411:23p p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Ownees Name
information is West Barnstable MA 02668 9A6-14
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fait 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.
El 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
Ei ® 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 is less than 6"below invert or available volume is less
than day flow i°/7—
[Sins•3113 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 4 of 17
Sep 161411:23p p.5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Uvo
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owner's Name
information is West Barnstable MA 02668 9-16-14
required for every _
page. Cityrrown State Zip Code bate of Inspection
B. Certification (cost.)
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 forma
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10.OOOg pd.
❑ ® 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
El ❑ 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-3113 Tula 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Sep 16 1411:24p p.6
Commonwealth of Massachusetts
__ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owner's Name
information is required for every West Barnstable MA 02668 9-16-14
page. CitylTown Slate 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 recent) or as art f
� ® 9 Y Y P o
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?
Q ® 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.
El ® 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): NA Number of bedrooms(actual). 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x*of bedrooms): 220
15ins-3113 Tile 5 official inspection Form.Subsurlace Sewage Disposal Syslem-Page 6 of 17
Sep 16 1411:24p p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owner's Name
information is required for eve West Barnstable MA 02668 9-16-14
page. every Citylrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal.Tank and pit.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Well Water
9 ( Y 9 (gPd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
CommerciaUlndustrial Flow Conditiorts:
Type of Establishment:
Design flow(based on 310 CMR 15.203): GaDons 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•V13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
i
Sep 161411:24p p.8
Commonwealth of Massachusetts
y
Title 5 Official Inspection Form
=I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owners Name
information is required for every West Barnstable MA 02668 9-16-14
page. CitylTown 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: 2010/
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 PP of the DEP approval.
❑ Other(describe):
tsinS•3f13 TAIe 6Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Sep 16 1411:25p p.9
<L\N' Commonwealth of Massachusetts
Title 5 Official Inspection Form
s. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Bames
Owner Owner's Name
information is required for every West Barnstable MA 02668 9-16-14
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20
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_):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
4"
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 Gal.Precast H -10
Sludge depth:
2"
t5ins Y13 Titla 5 Official Inspection Form Subsurface Sewage Disposal System-Page 9 of 17
Sep 16 14 11:25p p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owner's Name -`
information is squired for every West Barnstable MA 02668 9-16-14
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
28"
Scum thickness 2„
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 16'
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level.Tank and covers at 4" below grade. In and outlettee's. No sign of
leakage or over loading, maint pump after inspection.
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 Tile 5 011icial Inspection Fomr Subsurface Sewage Disposai system•Page 110 of 17
Sep 16 1411:25p p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Bames
Owner Owner's Name
information is
required for every West Barnstable MA 02668 9-16-14
page. Citylrown 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 El 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.3H3 rse 5 ainciai Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Sep 161411:26p p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Sames
Owner Owner's Name
required fo is West Barnstable MA 02668 9-16-14
required for every
page. City/Town State Zip Code Dale of Inspection
D. System Information(cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc_),
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ Not
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ird-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 or 17
Sep 161411:26p p.13
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
} Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owner's Name
information is required for every West Barnstable MA 02668 9-16-14
page. Cityfrown 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.):
i
Leaching is a 1000 pit w/6'shim,Total 12' deep. Pit and cover at 2'below grade, pit 1/2 full.
No sign of over loading or high stain line.
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
15ins•3113 Us 5 Official Inspedion Form:Sibsurface Sewage Disposal System•Page 13 of 17
Sep 16 1411:26p p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owner's Name
information
fired is every
West Barnstable
re aired for eve MA 02658 9-16-14
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.):
Sins-3113 Title 5 Official Inspection Form:sLbsLdace Sewage nisposal System•Page 14 d 17
Sep 161411:27p p.15
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owner's Name
information is required for every West Barnstable MA 02668 9-16-14
page_ CityFrown State Zip Code Date of Inspection
D. System Information (cost.)
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
13-1. 9
zECie
14
I
O
O
a
Wins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 15 ct 17
Sep 161411:27p p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
b 515 Cedar Street
Property Address
Lod Barnes
Owner Owner's Name
information is required for every West Barnstable MA 02668 9-16-14
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N�
Estimated depth t high ground water: 50'+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:
Per past report G.W. maps 50'+ to G.W..
Before fling this Inspection Report, please see Report Completeness Checklist on next page.
t5ins 3r'3 Title 5 Official Inspection Form:Subw6aca Sewage Disposal System-Page i s or v
Sep 161411:27p p.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
515 Cedar Street
Property Address
Lori Barnes
Owner Owners Name
information is required for every West Barnstable MA 02668 9-16-14
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Inspection Summary:A, B, C, D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
15ins•3113 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
�fs � � roq�o�C�7
LO CATION SEW E PERMIT NO.
VILLAGE /
INSTA/LLE/R'S NAME /i / ADDRESS
IUILDEIt OR OWNER
�7 e
DATE PERMIT ISSUED
g-3D-7q
DATE COMPLIANCE ISSUED ID- 17-71
I
:. �
l� �
O.
r ,
y
�FIMs......d.
••
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
U�
\O ......� .
4V.,0 ..............OF...... .Ct.tf 9 .( d. �------------
Appliration for llhipvii al Works Tonstru.rtiun frrutit
lication is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
PP Y (�) P ( ) g P
System at:
.......d.p.�...iC..!.....-SG_...r..-------'-_-.••---.-�--/•�-G•---.(./.✓--C-......s.s.......-------••--•--------------_..
tLA
.e . o & y--_ O,�"—
.-.------
ictc .... Add�_, -2W;k-4�-e-------------------------- �- i
Installer ; Address
d Type of Building Size Lot...-ZU�.D100......Sq. feet
U Dwelling No. of Bedrooms..... ....-rw—e----------------Expansion Attic ( ) Garbage Grinder 06)
04 Other— _yTe of Building ............................ No. of persons----------1-----..---------- Showers (a) Cafeteria ( )
P4 Other fixtures -------------------------------• .
W Design Flow................ja ..............--gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—.Liquid ca.pacitylD00 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 ( ) Dosinge sta-n�k, I( )
04 Percolation Test Results Performed by.-- s ►.. ,tM(?". 2................................ Date......7/z .....................
1.4
Test Pit No. 1................minutes per inch Depth of Test Pit................---. Depth to ground water..--....................
fi Test Pit No. 2................minutes per inch Depth of Test Pit..--................ Depth to ground water......----.........----.
a •---•---••-•-- ------ --------• --------------------.. .....
--.- .t�.1.t.. - --••-----_ —_=:--0 Description Qf Soil.
7--U
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 TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ssue by e 5atyrd o hea
4
Signe.._....- ;r - .._ t
PP PP By
Application Approved B ._..._._. ..
..................................•---•---Date ...........-
Application Disapproved for-the following reasons:................................................:.
--•--...------•.............................•-------•----.....--------------------------------
------------------
Date
PermitNo......................................................._ Issued.......................................................
Daft
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;OF ............................................................
A lir aialai 15tspoilat Works Tnnitrnrtinn ramit !
Application is hereby made-for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal
System at: t
..................'...........................................................
ocation t ddress or Lot o.
Owner Ad re s
Installer Addre
ss
Type of Building Size Lot_.?Xf pdd......Sq. feet
..� Dwelling—Vo. of Bedrooms......e!K._...C41pi@-_----_---_--Expansion Attic ( ) Garbage Grinder
'4 Other—T e of Building . No. of persons.........a YP g ------•-•----•-•----------- P � I----_-------_ Showers (� — Cafeteria ( )
Other fixtures ---------------•-••------------- •---.
d ...................•......•-----------.....----••-•.........•---
W Design Flow..............>�!:J�o7--.__._-_________gallons per person per day. Total daily*flow............................................gallons.
WSeptic Tank—Liquid capacity/1W.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.-__i................ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing ank ( )
Percolation Test Results Performed by...a0f. -4�............................... Date......?..............................
Test Pit No. I............:4..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........................
P+' ...................... -----•-•4-•....... ....... ••-_.....-----.....;1 --•----------.:......--------••--••-•--•------- _----...
O Descriptiop pf Soil.`.. kftle
..__..
W r ,.
UNature of Repairs or Alterations—Answer when applicable................................................................................._.._...........
--------------------------.........................................
Agreement:Y
The undersigned agrees to install the afore4cribed Individual.Sewage Disposal System in accordance with
the provisions of TITL2 5 of the State Sanitary Code—The undersigned further agre s not to place the system in
operation until a Certificate of Compliance has bee ssue by e d oj hea
_ . Signe �..
Application Approved BY... �+-----------•- ... at"
' t
Da e
Application Disapproved for4he following reasons:......................................................................................... •---•--••••--•--•-
r
..-------•---------------------------------------ai;...--••--•-------------------.._....----•-------•------•--••---------•--.____..---------..._..:_...---.---•-------•----••-----.._ ------•-•-•---
Date
PermitNo.............. ........................................ Issued-------- -•-•-----------•-------
D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OEALTH
..�J !! !�.....O F................ ... ...... .. . . ..
Tntifiratr ,af TautpliFatta
,,�IS SW..X.T�
FY, That the, Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..l4•'•� at --- ---- ---•-•--------
//����,, �» Instal
at .�G �� � ----- b .............................................................
has been installed in accordance with the provisions of T j �f The State Sanitary C de as described in the
application for Disposal Works Construction Permit No.__ �±._ �.:p'......... dated__... :: . -_. "_ ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
l _ _ y
DATEf............................................................... Inspector.---.. ---- - ------------._----------------_-._-_--------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....ro .................OF..... �d+ / # °f---.....................-------:....... d"p
7 .r
No........ .�... FEE.... 0...........
M i n I arks Tnnsirnrtion ranfit
Permission is hereby granted.. l_ .....00,-----�-1-A74 17..................................................
to Constr ct O or Repair ( )�yan, Individual ,Sewage Disposal S stem ,
at No. 4 � C• Wf'` WAPP-t-........... y >/l 4 ,v------- !- 6exsAj1,r------•-
Street +
as shown on the application for Disposal Works Construction Per` it No _..__�f....._ Dated....`�''_�.d.
- i' 'h -••-••-••-•-....._
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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BORTOLOTTI CONSTRUCTION, INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION/FORM
Xddress Of Property S15�Giri`.5,� G✓� �` lj'rl h6/e
Owner's Namet`G GjrlP l�L,rJ Ll�i�/
Date Of Inspection
PART A
CHECKLIST.
Check
if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
✓ None of the system. components have been pumped for at least two weeks and the
system has been receiving normal flow rates during that period. Large columes
of water have. not been introduced into the system recently or as part of this
inspection.
As-Built plans have been obtained and examined. Note if they are not avail-
/ able with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected. for signs of breakout.
All: system. compopphts, excluding the SAS, have been located on the site.
The septic:tank manholes:were uncovered, opened, and the interior of the septic
tank .was inspected .for.condition of baffles or tees, material of construction,
dimensions, depth:.of liquid, depth of sludge, depth of scum.
The size and location of the SAS on the site has been determined based on exist-
ing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with
information on the proper maintenance of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
j number of bedrooms
O number of current residents
AP garbage grinder, yes or no
'V615 laundry connected to system, yes or no
5 seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
5ee5 e Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
U
y� System pumped as part of inspection, yes or no
if yes, volume pumped
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) /
✓/ Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
�l L/ o l vs die
/0 Sewage odors detected when arriving at the site, yes or no
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION CONTINUED
SEPTIC TANK:
(locate on site plan)
depth below grade: IZ /
material of construction: ✓ concrete metal FRP other(explain
dimensions: f0 L GCS ti/f 6
y sludge depth
3 distance from top of sludge to bottom of outlet tee or baffle
a
/4 scum thickness
distance from top of scum to top of outlet tee or baffle
/Z distance from bottom of scum to bottom of outlet tee or baffle
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, ecommendations for repairs, etc. )
7-� 4(/--/&ew1 e 1-4'1 At; o 041
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence
of leakage into or out of box, recommendation fro repairs, etc. )
PUMP CHAMBER: -
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART. B
SYS`I�I"I �ORMATION CONTINUED
SOIL ABSORPTION SYSTEM (SAS) :
(locate:on .site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number _
leaching trenches, number, length
leaching .fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
CESSPOOLS (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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, 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, recommendations for maintenance or repairs, etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEMON FORM
PART B
SYSTEM INFORMATION CONTINUED
SKETCH OF SEWAGE DISPOSAL SYSTEM;
include ties- to at least two permanent references landmarks or benchmarks
locate all. wells within 100'
2_57 l q
ys-
7z.�
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
Lot dAle yatl® aye ( rqv ti1 // ���o�nuy` l�va�f�l7s --
SUBSURFACE:.SEWAGE>DISPOSAL.SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of
determination in all instances. If "not determined", explain why not.
/v Backup :of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
y�f Liquid depth in cesspool, 6" below invert or available volume, 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of .times pumped
A/ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy,
below the high groundwater elevation?
Within 50 feet. of a surface water?
_Within 100 .feet of a surface water supply or tributary to a surface
water supply?
,y Within a Zone I of a public well?
41 Within 50 feet of a private water supply well?
,y Within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS)?
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, amonia nitrogen
and nitrate nitrogen.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CEEtTIFICATION
Na of Inspector: p!�G/'jf Nam ,q,"fOZ,
Company Name
Company Address
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address. and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maintenance of on-site -sewage disposal systems.
Check on
v I have not found any information which indicates that the system fails
to. adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15.303. The basis for this
determinimation is provided in the FAILURE CRITERIA section of this
form.
Inspector's Signature
Date
Original to System Caner
Copies to:
Buyer (If applicable)
Approving authority
r
Page: . 1
f CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report Dated: 05/18/2000
Report Prepared For: .
Order Number: G0005872
William Barnes
158 Drake Avenue
Staten Island, NY 10314
Laboratory ID#: 0005872-01 Description: Water-Drinldng Water
Sample#: 05872 Sampling Location: 515 Cedar St.,West Barnstable Collected: 0 511 0/2 0 0 0
Collected by: R.Gibson 109/062 Received: 05/10/2000
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 1.1 mg/L 10 EPA 300.0 05/12/2000
LAB: Metals
Copper 1.0 mg/L 1.3 SM 3111B 05/17/2000
Iron 0.1 mg/L 0.3 SM 3111B 05/17/2000
Sodium 10 mg/L 20 SM 3111B 05/17/2000
LAB:Microbiology
Total Coliform Absent P/A Absent P/A 05/10/2000
LAB: Physical Chemistry
Conductance 130 umohs/cm EPA 120.1 05/11/2000
pH 6.1 pH-units EPA 150.1 05/11/2000
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:
(Lab Director)
rh he 0
r
Superior Court House, PO.Boa 427, Barnstable, MA 02630 Ph: 508-375-6605
No.- ' ',-, Fee— �-�---
BOARD OF HEALTH
TOWN OF BARNSTABLE
Z.ppticat ion-*rVell Cootruction3permit
Application is hereby, made for perm•t to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
Loc ' n — Address . Assessors Map and Parcel
Owner Address
NON
Installer — Driller Address
Type of Building
Dwelling -- - --- - -------------------------
Other - Type of Building No. of Persons------
TypeCapacity
— -----------
of Well—--r — Capacity ----— _-----
Purpose of Well -�04 --------—__
Agreement:
The undersigned agrees to install the aforedescrib'ed 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 Certific to of iance has been issued by the Board of Health.
Signed ----—-
date
Application Approved By ---- -—------- -- - —
date
Application Disapproved for the following reasons:
date
Permit No.— —~ Issued-------_ '_' J
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of Compliance
THIS IS O CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (t/�
by---
�j Installer
at C V C r r__
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
p
kegulation as described in the application for Well Construction Permit No. � ��ated f �/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -- --—- ---------- ---- -- Inspector— -- --- -- _—__--- — - —
Fee—
BOARD OF OF HEALTH
TOWN OF BARNSTABLE
Ztp'rtcation,1orwelt Con6trUtti Oil permit
f�
Application iss�hereby
�m
a
de/for a permit
to ConstruQc�t, ( ), Alter ( ), or Repair ( )an individual Well at:
Location — Address Assessors Map and Parcel
Owner Address
- - - �
70 ------------------------------------------------------------------------------------------
Installer — Driller Address
Type of Building
Dwelling--- r
-----------------------------------------------
Other - Type of Building -------- No. of Persons------------------------------------------------
Typeof Well--------------------- -------------------------------------------- Capacity----------------------------------- -- -------------------------
Purpose of Well �-----------------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
r 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 -ompliance has been issued by the Board of Health.
Signed - -� '` - !— �.- -----
----------------—-------------
date .
�� 9-----Z-- -���'_--G '------------ - f
Application Approved By----____._________
J` date
Application Disapproved for the following reasons:------------------------j---------------------------------_-------
--------------------------------------------------------------------
,,��----++ date
PermitNo.------ N— f z7__ -------------------------- Issued------------------- - `-----------------------
date `
r
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (V)
bY- —<-�- - �'_'- ✓-_ 't ----------------------------------------------------------------------------------------------------------------------
Installer
at-- t ('°► =— ! j l-x_ ---------------------------——— — — —has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. = Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--- - - - - - - - Inspector------------------------------------------------------------ --
BOARD OF HEALTH
TOWN OF BARNSTABLE
Veil Con5tructionVermit
Fee------ ---- ---
Permission is hereby granted-------" - --
to Construct ( ), Alter ( or Repair (✓) an Individual Well at:
No. - -- � _ {_.�5 _y!__ � ` �/ G1�L� /__`s__ / -------------------------------------------------------------------
Street
as shown on the application for�aWee,.11 Construction Permit g�
No.--- -9�---------------tJ-------------------------- Dated--------- --------------------------
� Board of Health
DATE - '„r-----`-- --- r ���
- --- --- Fee---- ----
No.- ---- -----------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application-*rVe[C Con0ructioni3ermit
Application is hereby made for a permit to Construct (V), Alter ( ), or Repair ( )an individual Well at:
Location — Address Assessors Map and Parcel
Owner Address
------- -!�4_t ,G. -�J� ��� _�=Ctt �-------- _
---------------------
Installer — Driller Address
Type of Building /
Dwelling----- ----------------------------------------------
Other - Type of Building----------------------- No. of Persons--- --------------__--__ __
Type of Well -Lf 4 — Capacity----����----- —?- -
Purpose of Well----- !''�-K-t----- � ��- In.,si-Z51
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The J
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 ompliance has been issued by the Board of Health.
�L�
Signed -- --- _ —� I
date
Application Approved By
date
Application Disapproved for the following reasons: --------------------------------------__— _____
--------- ---- ------------------------ --------------------
date
1
Permit No. — -- Issued— ------�-- __
d e
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO M Th the Indi du 1 Well C strutted ( )b k=�, ------- 1�f>
, tered ( ), or Repaired ( )
—
. -
LCOM Install- � =:at---has been installed in accordance with the provisions of a Town of Barnstable Boa He t Private Well Protection
Regulation as described in the application for Well Construction Permit NoW 4eDated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---- Inspector----------_-___— _
r. +1..iy�YSNri.-rr� . Jy+' '•r.-,K..�H..M•T..". _ '.'
--- ---- //v//11 ----- ----
No.- --- Fee -- --- !
BOARD OF HEALTH
TOWN OF BARNSTABLE
application,for Velr Construction Permit
Application is hereby made.for a permit to Construct Alter ( ), or Repair ( )an°individual Well at:
Location ,Address .- Assessors Map and Parcel,
Owner " Address'
--------- -,K ------ ? -OTC- -
Installer- Driller Address
Type of Building Y
Dwelling--1e-----—------------------------------------------
-Other - Type of Building No. of Persons---G------------ ,�---------
Type of Well—=_ — -�� ---- Capacity--- - -
- -- "
Purpose of Well - - 4--- -Lis r_ �)f�S� C�.�c C..�it {�V C 1 i
E '
en(-O'(2�t- oc.4�. �r(v. ci enu)t 71�,
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of e ,�—
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 ompliance has been issued by the Board of Health.
Signed —
date
Application Approved By -__—i' '" _----
date
Application Disapproved for the following reasons: ------------------ ------- --
} date
f +�
` Permit No. Issued-- ----- -- -- --dale
BOARD+cow?i.9wadtcs�!Fi4ili9i'fv1b9o''!i-ese9di.o'Eu le4<iisio4'i't�oCeRp?.i'Xe�eldbi4e+Yaler)Sfafl.N6ldwK'�6c'�¢.bGailF2tlsditfifi�.FkYi'si!'ifieTe"fLtili�GYrPHb']21taw�:l�T.eeLPe9-aYAEr!tlo`1�abaseP_k.NTL!'i�s'.S
BOARD OF HEALTH
TOWN OF BARNSTABLE `
r
Certificate Of Compliance
THIS IS TO RTI Th the Indiv'du 1 Well C structed ( ), Altered ( ), or Repaired ( )
Installer
at— — 15 C60 A d2 -
has been installed in accordance with'the provisions of e.Town of Barnstable B((oa He �tPrivate Well Protection
Regulation as described in the application.for Well Construction Permit No.ta4 bated---- ----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE.CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
I .
kt DATE— -- -- — Inspector— -
1 o"t"`�'1°"^`Y+' ?`WN w•* ;�•' 't r r° rii+.+E' r-s T� a!! ..rnaxgr �, W.mt. �,,.r�.,.y�x _ .—'--- --- _—_ --------
t�t
+-.a-..l••r.:-..-Yrfc'fawn!uecr;ttilv."+..z+.1+.aoLTuawY$'"i--�a3nEallsTdMtFM�Pi. 0��1^c"siSLFC6s....,._.�iP.L'mS+vf_SS�'1iNt�liF_• idilv^iK®i�d4�h�dAM-41iYL�i�Fi�i�i^i��ri•}.i.PiTEao.{,
t BOARD OF HEALTH
TOWN OF BARNSTABLE
Veil ctCon5tructionPermit
'! No. JA) C Fee - ---
Permission ' hereby granted —_—
i
to Construct ( ), 41tq ( )ti or gpair )kneiviouaIUMell at:� 1107,
Street
as shown Vy7fication for Well Construction Permit
No. - Da
ted--^— --------------------
-
Board�o'y ealt
DATE (//
i
i
cvras c,cacra,—�,7
O
• l.Jr Gam,c�1�
la--i5� 1
c�� m►�t hi �t=a7
• Material and Labor Sheet
•
PAUL JENKINS &SONS,INC. Date
Plumbing & Heating -Well Drilling
P.O. Box 5 Rt. 39 So. Orleans, MA 02662 Time
Name of Job Time
Location
Day Work Rate Hour Day
Contract Work Mechanic Mech.
Extra Work Helper Help.
QUANTITY STOCK—DESCRIPTION - AMOUNT
Y
r
J
REMARKS: Form 101 Harrison,Littleton, NH 03561