HomeMy WebLinkAbout0611 CEDAR STREET - Health L611 CEDAR STREET, W. BARNSTABLE
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TOWN OF BARNSTABLE
LOCATION v!� efgW&, SEWAGE
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VILLAGE�/�/, QQ,,t/, ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO�o
SEPTIC TANK CAPACITY / 420
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS _
OWNER Ju pr L-
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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as� ����
S�S� 'F441 a;
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6 No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD O�F�. `HEALTH
APPLICATION FOR D SPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components
o io l ne' ame
ap ar el# Address
Lot#
1 11 ' Na Designe�•rr''sNaarne G
/ /
ynj
d rest. Address
rf
Telephone# I Telephone#
�96
Type of Building: . 0 F v 1 ► Lot Size Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required) gpd Calculated design flow gpd Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS O LTER ON 10-y 'P/T /
�(
The undersigned agr a to ins ta above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and furthe gr not to pl a th system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
NO. THE COMMONWEALTH OF MASSACHUSETTS FEE L90
BOARD OF HEALTH
APPLICATION FOR D SPOSAL SYSTEM CONSTRUCTION PERMIT
truct Application for a Permit to Cons ( Repair ( ) Upgrade ( ) Abandon ( ) ❑Complete System ❑Individual Components
ap arcel# Address
)OP
Lot Teleph�
I Iler's Na Designer's Name(
d ress Address
Telephone#' Telephone#
r
Type of Building: �� �v 1 Lot Size Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( ~ )
Other fixtures
Design Flow(min.required) gpd Calculated design flow gpd Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR—ALTER) ONS e T /io
The undersigned agr a to insta above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and furthe not to pl Meth system in operation until a Certificate of Compliance has been issued by the Board of Health.
' p
Signed Date
,Inspecfions
• i
I
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
�.—
No.�Z�;HE COMMONWEALTH OF MASSACHUSETTSI FEE! env`. : � BOARD OF HEALTH
CE
RTIFICATE OF COMPLIANCE
Description of Work: Component(s) ❑Complete System
The undersigned
�hereby certify that the Sewage Disposal System;Constructed( paired( Upgraded( ) Abandoned( )
at
has been installed in accordance wi h the_p o//v,,iisions of 310 CMR 15.00 (Title 5) and the approved design lans/as-built
�-^-plans relating t application No. l,) Gated Approved Design Flow (gpd)
Installer A /l
Designer: Inspector !'!/ !/i IY 1 # Dat+/e'V�
The issuance of this certificate shall not be construed as a guarantee that the system will function as-designed. �} f
FORM 3 - CERTIFICATE OF COMPLIANCE4 DEP APPROVED FORM 5/96 -
--a
No. C14HE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
ITV
DISPOSAL SYSTEM CONS�;RUCTION PERMIT
Permission is here r nted o onst u (� ) Re air (✓ Upgrade ( A ndon ( ndi 'dual sewage
disposal system at � Was described
in the application for Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON
CERTIFICATE OF ANALYSIS Page, 1 of 1
Barnstable County Health Laboratory (M-MA009)
Report Prepared For: Report Dated: 10/10/2014
Sally Desmond
Desmond Well Drilliig Order No.: G1483829
P O Box 2783
Orleans; MA 02653
Laboratory ID#: 1483829-01 Description: Water-Drinking Water
Sample#: Sample Location: 611 Cedar St.W. Barnstable, MA Collected: 10i09/2014
Collected by: Customer Received: 10/09/2014
Test Parameters
ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE
Total Conform Absent P/A 0 0 SM9223 RG 10/9/2014
Water sample meets the recommended limits for drinking water of all the above tested parameters.
....-......_....— __ .. ---- _ - ------—
Attached please find the laboratory certified parameter list. Approved By: u" `
(Lab Director)
i
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
'Town of Barnstable w ,V Barnstable
SFiE T
Regulatory Services Department 1AFAm e,caCity
anxvsra6LY,
9 MASS. Public Health Division m
fD""w�a 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Division Manager
CERTIFIED MAIL# 7012 1010 0000 2851 0848
October 9 2013
V
Griffin J White & Daniel J White
611 Cedar Street
West Barnstable, MA 02668
CORRECTED TIME FOR REPAIR
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 661 Cedar Street, West Barnstable, MA was last inspected
on September 10, 2013, by Sean M Jones, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Tank and distribution box must be replaced.
• Well must be tested before transfer of property.
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
��om�ascKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\conditionally passed\61 I Cedar St W Bam 2013.doc
I '
® Complete items 1,2,and 3.Also complete A. to
item 4 if Restricted Delivery is desired.
o Print your name and address on the reverse Agent
so that we can,return the card to you. _ Addressee
® Attach this card to the back of the mailpiece, B ece' ed b ( rioted Na e
or on the front if space permits. C. Date of Delivery
t. Article Addressed to: D. elivery address different from item 1? O'Yes
If YES,enter delivery address below: ❑No
�• � — < j
Griffin.-:J Whit �?CZt'F1 i v1& Daniel J White
611 Cedar Street
West Barnstable, MA 02668 3. Service Type j
1:1 Certified Mail ❑EX
❑Registered ❑Retur Re }
Insured Mail Eldise C.O.D. PS I
{ 4. Restricted Deliver
y?• (Extra Fee) ❑Yes
I 2. Article Number-
-
(Transfer from seivice.labelJ 7�12 1�1
0000 2851 0848
I PS Form 3811.February 2004 � �•
Domestic Return Receipt.
f02595-02-M-1540
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MI
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s.: AA
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nO fIJ Postage $ J `
C3 Certified Fee ` N
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Return Receipt Fee S PO
O (Endorsement Required)
APO
CD Here
Restricted Delivery Fee
I_7 (Endorsement Required)
O Total Postage&Fees ru
r�
d Griffin J White & Daniel J White
611 Cedar Street
West Barnstable, MA 02668
L 1
• T Town of Barnstable Barnstable
Regulatory Services Department
i
• "� LE, Public Health Division �-
�Eo 39. a 2007
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 1010 0000 2851 0077
September 26, 2013
Jude White
611 Cedar Street
West Barnstable, MA 02668
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5.
The• septic sy stem located at 611 Cedar Street West Barnstable, MA was last
inspected on 9/10/2013, by Sean M. Jones, a certified septic inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally
Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) Due to the
following:
• Tank and distribution box must be replaced.
• Well must be tested before transfer of property.
You are ordered to repair or replace the septic system within sixty (60) days
from the date you receive this notification.
Failure to repair/replace the septic system with the deadline period will result in
future enforcement action.
PER ORDER O THE BOARD OF HEALTH
CS
cKean, R.S. CHO --v to;
• Agent of the Board of Health
Q:\SEPTIC\conditionally passed\61 I Cedar St W Barn Sept 2013.doc
o Complete items 1,2,and 3.Also complete A. Si
item 4 if Restricted Delivery is desired. gent
X o Print your name and address on the reverse Addressee
so that we can return the card to you. B R el e
o Attach this card to the back of the mailpiece, Y P rated ame) G. Date of Delivery
or on the front if space permits.
1. Article Addressed to: d ivery address different from item 1? ❑Yes
I ES,enter delivery address below: '❑No
i
Jude White
i
611 Cedar Street '
3
West Barnstable, MA 02668 El Certified Mail ❑Express Mail
❑Registered ❑Return Receipt for Merchandise
❑.Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fed) ❑Yes
2. 1 u er ( 7012 1010 0000 2851 0077 All sfer fr m service label)
PS MM3 11. February 2004 Domestic Return Receipt _--__—_ f.o2sss-o2-M-15ao_— — Domestic
�'.
rti • �
Q
Q
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Ln
43 Postage $
ru
Q Certified Fee .w�
Q �.,
Return Receipt Fee i� Postmark,
Q (Endorsement Required) Q Here ` • ?:
Restricted Delivery Fee Z
Q (Endorsement Required) SEp 2 4 2013 ~1
r�
Q Total Postage&Fees ��
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nub v� .�-
r- Jude White
i 611 Cedar Street
West Barnstable, MA 02668
I
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
611 Cedar St
................................................. —
_.
Property Address.
Jude.White .
Owner Owner's Name
information Ps
required for Every. West Barnstable. — Ma_ 02668 M 01201.3
_.: page. Cityrrown State Zip Code !:' Date oflnspection
Inspection results must be submitted on this form. Inspection forms may cot be altere l'tn arty,
way. Please see.completeness checklist t the end of`the f6rM
fImportant:gout ms A. General information
. .
filling out forms I
on the computer, (�
use only the tab ctor: Cv
key to move your
1: Inspe
cursor-do not Sean M. Jones _
use-thereturri _.____� _ _ -
Name of Inspector
key:
�ewide Enterprises
Company Name
153 Commercial:St.
Mashpee Ma 02649
Gltyrrown State 2ipCode;
508-477 $877 S1 4522'
..._ .. .. ... -_
- -
Telephone Number license Number -
B. Certification
I certify that I have personally.inspected the sewage disposal system at:thls add'tess a'nd that;the
information reported below is.true, accurate and complete;;as of the time'''of the inspection. The Inspee#Ion
was performed based on my, training and experience in the proper function.and maintenance of on site
sewage disposal`systems. I amp a DEP approved system inspector pursuant to Section iu of
Title 5(310 CMR 15.000) The system: o
❑.Passes Conditionally Passes.. ❑ Fails
❑ Needs Further Evaluation by wthe Local Approving Authority
{ ' 9/10/201:3
.... . ....._,.
.... .......
. ... .... - - -
Inspector's Signature. Date
The:system.inspector shall submit a copy,of this inspection report to the Approving Authotity{Board
of Health of DEP)within 30 days of completing this in pection if the;system is a shared system;or
has @iAesign flow of,10,000 gpd or greater, the inspector arid:the system owner shall suornit the
report to tlie:appropriate regional offi"ce of the,D'EP. The original should be sent to;;the system owner
and copies sent to'the buyer, if applicable, and the approving;authon y
... __ ----------
****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 theJuture.under':
the same or different conditions of use.
d
t5ins•3113:I Title 5Official Ins pa .on an,Subsurface Sewage;0isposa!System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
a)The septic is h-10 loading and located in the driveway under asphalt.
b) The septic tank is decaying and was found to be brittle
c) The distribution is also h-10 located in the driveway
d)The distribution box is rotted at the water line and had exposed aggregate.
l5ins•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
�M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is West Barnstable Ma 02668 9/10/2013
required for every
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
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
10 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
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 of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
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): 5 Number of bedrooms (actual). 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 gpd
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
.'' 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (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 years usage (god)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
ICI
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed if known and source of information:
P 9 P ( )
original system installed 9/24/1976 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joint were ok, no leaks, vented through the roof
Septic Tank (locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
L Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
•
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
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
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.):
Septic tank was found to be decaying, the concrete was rotting and had exposed aggregate. The
septic tank is h-10 and located in a paved parking area. Town of Barnstable regulations require all
septic components to be rated h-20 ( heavy duty) if they are located in an area designated for driving
or parking.
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•3/13 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
611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information lis required for every West Barnstable Ma 02668 9/10/2013
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
L Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M ,•''r 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The distribution box was found to be decaying, the concrete was rotting and had exposed aggregate.
The distribution box is h-10 and located in a paved parking area. Town of Barnstable regulations
require all septic components to be rated h-20 ( heavy duty) if they are located in an area designated
for driving or parking.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins•3113 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
,M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
2x1000 gals
❑ 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.):
The leach pits are also located in the parking area but are rated h-20. Pit(#3 on asbuilt)was found to
be dry with no sign of past hydraulic overloading. Pit(#4 on asbuilt)was found to have approx 2' of
standing water with no sign of past overloading. The pits have steel covers to grade.
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. City/Town 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
611 Cedar St.
- _
- _-______ .:...................................._.......:
Property Address W...__
Jude White
Owner _...... ,.. . .:.. --
Owner's Name
information is West Barnstable,. Ma 026.6.$ 9(t012013
required for every _ —
page: City/Town State Zip code: Date of inspection
_..
_ o System Infldirmation (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal "system,,inciudtng ties to
at least two permanent reference landmarks or benchmarks_ Locate ail 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
. ............
............
�¢ z
a
c
-�
13--2
a�-3
Tb
133
64. 2
15ins--3113 Title 5 Official Inspection Form:Subsurface Sewaga Disposal spt6m•Page t,5 of 17: .,
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
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:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
4
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for every West Barnstable Ma 02668 9/10/2013
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A B C D, or E checked
P rY
® 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the l
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
faa P.O.Box 763 S2 p
Company Address `
Centerville Ma. c 026322
City/Town State Zip CodeN
(508)428-4028 S14454 %0
Telephone Number License Number 'ts
B. Certification w m
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
�-, 10/25/2010
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.
lO
t5ins•09/08 Title 5 Official Inspection Form:Subsurface S wage Disposal System-Page 1 of 17
T I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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 septic system is in porper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a brokers, 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Well Water
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 10/25/2010
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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•09/08 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 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30"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.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
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 gallon
Sludge depth:
5"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No
t5ins•09/08 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
611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is level.box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 TiUe 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
M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches. number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Both pits had approx 1' of water on bottom at time of
inspection.Stain line observed approx 3' below invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
'
every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W.garnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
Y. 0 . .s
\ w� tit icy
•• 1 I�vf
_� T' +t\
1
1 I
�t V
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 80'
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:
As-Built
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 611 Cedar St.
Property Address
Jude White
Owner Owner's Name
information is required for W Barnstable Ma. 02668 10/25/2010
i
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
i
ATLANTIC ENVIRONMENTAL �I /
P.O.Box 2384 v
� i Mashpee,Ma. 02649
m
Attn: Commonwealth of Massachusetts Date: 12/18/95
Town of Barnstable
Board of Health
367 Main Street
Hyannis MA 02601
From : Mr Michael DeDecko
Po Box 2384
Mashpee MA 02649
Dear Board of Health Official;
I certify that I have personnally inspected the sewage disposal system at the following
address : 611 Cedar Street-West Barnstable, Mass.
The information reported is true, accurate and complete as of the time of the inspection.
I have not found any information which indicates that the system fails to adequately
protect the public health or the Environment.
If you have any questions regarding this inspection,please contact me at this number:
(508)477-14-20. Thank you.
Sincerely,
Michael DeDecko
P � )
hone 508 477-1420
i
K06-c,� fCfAro
Commonwealth of Massachusetts , 1�91
Executive of Environmental AffairsDEP
� �;C
W'/r
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: k.\% Cf.A,3.--, sT. �. r0o ,
Address of Owner:
(if different)
Date of Inspection:
Name of Inspector: v-\,c), �
Company Name, Address and Telephone number:
Oor z32 y
— I LA 2 0
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported below is true, accurate and complete as of the time of
inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of on site sewage disposal systems. The system
Passes
--•- Conditionally Passes
•--- Needs further evaluation by the local Approving Authority
-- Fails
Inspector ' s Signature: 11ceLD ate:
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (30) days of completing this inspection. If the system
is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the
system owner shall submit the report to the appropriate ,regional office or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if applicable
and the approving authority.
r
„t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: to It Ck,&,, gT, ►.,, 3 y 10-
Owners :
D ate of Inspection : t Z1 V l
INSPECTION SUMMARY:
Check A, B,C,or D
A)SYSTEM PASSES:
-X I have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are
indicated below
B)SYSTEM CONDITIONALLY PASSES:
---- One or more system components need to be replaced or repaired. The system,upon
completion of the replacement or repair, passes inspection.
Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all
instances. If "not determinated", explain why not.
--- The septic tank is metal, cracked, structurally unsound,shows substantial infiltration or
exfiltration , or tank failure is imminent. The system will pass inspection if the existing
septic tank is replaced with a conforming septic tank as approved by the Board of
H ealth.
-•-- 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. The system will pass inspection if (with approval of the Board of.
Health).
----- broken pipe(s) are replaced
---- obstruction is removed
----- distribution box is levelled 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address.Owner : G �
Date of Inspection: 15 S
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health , safety ,and the environ-
ment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETYAND THE ENVIRONMENT:
---- Cesspool or privy is within 50 feet of a surface of water
---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT.
---- The system has a septic tank and soil absorption system and is within 100 feet to a
surface water supply or tributary to a surface water supply.
•--- The system has a septic tank and soil absorption system and is within a Zone I
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 primate water supply well,unless a well water analy-
sis 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 notrogen is equal to or less than 5 ppm.
D) SYSTEM FAILS:
•-- I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM 15.303. The basis for this determination is identified below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
---• Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Ul t Coda. ST w, 6ru.,a b _
Owner:
Date of Inspection:
D SYSTEM FAILS continued
--- 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 over-
loaded or clogged SAS or cesspool.
--- Liquid depth in cesspool is less than 6" below invert or available volume is
less than 1/2 day flow.
-- Required pumping more than 4 times in the last year NOT due to clogged
or obstructed pipe(s).
number of times pumped
-- Any portion of the Soil Absorption System, cesspool or privy is below the Neigh
groundwater elevation.
--- Any portion of cesspool or privy is within 100 feet of a surface water supply
ortributary to a surface water supply.
---Any portion of a cesspool or privy is within a Zone I of a public well.
--- Any portion of a cesspool or privy is within 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 ana-
lysis. If the well has been analyzed to be acceptable, attach copy of well
hater analysis for coliform bacteria, volatile organic compounds, ammonia
nitrogen and nitrate nitrogen.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1
Ca
a)c,, w sT �wr
Owner:
Date of Inspection
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above :
The design flow of system is 10,000 gpd or greater Large System and the system
is a significant threat to public health and safety and the environment because
one or more of the following conditions exist :
--- the system is within 400 feet of a surface drinking water supply
--- the system is within 200 feet of a tributary to a surface drinking water supply
--- the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area -IWPA)or a mapped Zone 11 of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00.
Please,consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: l C,ea�
T—UN . d _sz-,Tw b1�
Owner:
Date of Inspection:
Check if the following have been done:
X 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 the 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.
y- The facility or dwelling was inspected for signs of sewage back-up.
-Y The 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 the site.
The septic tank manholes were uncovered, opened and the interior of the Sep-
tic tank was inspected for conditions of baffles or tees, material of construc-
tion, dimensions, depth of liquid, depth of sludge, depth of scum.
}.t The size and location of the Soil Absorption System on the site has been deter-
mined based on existing information or approximated by non-intrusive methods
X The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
1
j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: O ,►�
Date of Inspection: \z`
RESIDENTIAL:
Design flow : q q O gallons
Number of bedrooms : �1
Number of current residents: o Z
Garbage grinder (yes or no): No
Laundry connected to system(yes or no): S
Seasonal use (yes or no): i,�
Water meter readings, if available:
Last date of occupancy:
COMMERCIALIINDU�STRIAL :
Type of establishment:
Design flow : gallohslday
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:
Other: (Describe) ............................................................................................................
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information :
N
System pumped as part of inspection(yes or no):.s;:> a..........
if yes, volume pomped : .................... gallons
Reasonfor pumping . ........................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of inspection:
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) and source of information
�.1° QL? �..af..!ry ..,. . .. ... �t�. ,. 'Q-r..............................
i.
...............................
Sewage odors detected when arriving at the site : (yes or no)....PQ..
SEPTIC TANK:
(locate on site plan)
Depth below grade: ..!?
Material of construction: ...n-concrete ......... metal ........ FR P ........ other(explain)
.. ................................................................. .. .
Dimensions: .�.r;..�.4. .�
Sludge depth :....1 a.......
Distance from top of sludge to bottom of outlet tee or baffle:......a:6
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:....IS..................
Comments :
(recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid
Ievel in relation to outlet invert, structural intQgri ,evidence of leakage, etc.). ►4a...hmaA
F J�1Q�.^? C�'7f�!:�_ �Ticx1.. �.p�'^.1........,.7d��r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: bt k
Owner: �N
Date of inspection:
GREASE TRAP : ....P.Q.......
(locate on site plan)
Depth below grade: ...............
Material of construction: ........concrete.........metal........FR P........other(explain)....
..........................................................................................................................................
D imensions:...............................
Scum thickness:........................
Distance from top of scum to top of outlet tee or baffle:.............................
Distance from bottom 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, etc.)........................
................................................................................................................................................
. ..................................:.............................................................................................................
TIGHT OR HOLDING TANKS:..!)<?...
(locate on site plan)
Depth below grade:...............
Material of construction:........concrete........metal.........FR P..........other (explain)..........
...................................................................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallons/day
Alarm level:.............................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
................................................................................................................................................
................................................................................... ....................................................
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: L-� k Ca� 5T. 1N, �eteotisTatl���- , u
Owner: OL�,Qs� .
Date of inspection:
DISTRIBUTION BOX:...��5
(locate on site plan)
Depth of liquid level above outlet invert:...! .,.
Comment:
(Hate if level and distribution equal evident of solids carryover aviderice of leakage into
or out of box,a ... �. ..g. � ,. .
................................................................................................................................................
PUMP CHAMBER:
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)....................
................................................................................................................................................
................................................................................................................................................
SOIL ABSORPTION SYSTEM (SAS):.:t�yt,&........
(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, number: .,p?-'..�a
leaching chambers,number:........
leaching galleries, 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 Negetati
etc.)..(,6�' SA ...
v.Qv
�
p.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: ro r t INP-NsTi�(j��
Owner:
Date of inspection: t 2\
CESSPOOLS:.....Nv..
(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
Indicator of ground water: ....................
inflow (cesspool must be pumped as part of inspection)
..: .................................................................................................
...............................................................................:.................
Comments:
(note condition of soil,.signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
.: ................................................................................................................................................
PRIVY : ...l,).c
(locate on the site) .
Material of construction: ...................................
Dimensions: ......................
Depth of solids: ................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
................................................................................................................................................
................................................................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address : G6� %-,v, C�3,
Owner: �w
D ate of inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'.
NS*r4m 1ve-4-0 ,
IN bovep.t..ta wl
R�SC¢J
- �soc>�fll s�T
•
0 9,��,.g,oNs
4 c_ 33,e
o e
DEPTH TO GROUNDWATER:
Depth to groundwater: 5 ...feet
Method of determination or approximative:
z.. . �1 �..3a.f....y.` ....................................................................................
................................................................................................................................................
.LOCUTION ' SEW&GE PERMIT UO.
- - 11 — st - - - - - - - -
NALLAGE
ItJS7QLLER5 ► WE 6 ADDRESS
BUILDER 'S Q AAAE ADDRESS
DNTE PERMIT 155UED
DATE COMPLI &KICE ISSUED ;
HoW
i jj/
Fil
C i
i►
No...... y ....... Fizs.....r�
�1I, THE COMMONWEALTH OF MASSACHUSETTS
bq BOARD OF HEALTH
J ...... --- ---- - --------OF..................................... ............-------------.........................
Appliratiun -fur Mupuual Vorkfi Towitrurtiun PPrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
%1410/�_ U/G-j.cJ
............... ..................................... ................Z
L tion-A dress or Lot No.
•.
caner Ad c .
Installer Address
d Type of Building Size Lot.... .......� Sq. feet
U Dwelling—No. of Bedrooms---------- '-----------------------------Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons.---_.__.___________.______- Showers ( ) — Cafeteria ( )
Q' Other fixtures .....___
d --------------------
W Design Flow------------ ......................_A .gallons per person per day. Total daily flow._..._....Y.#__Q-_______-___._----.---gallons.
WSeptic Tank—Liquid capacity __gallons Length---------------- Width................ Diameter---------....... Depth-.-.._--__._----
x Disposal Trench—Ao. .................... Width.................... Total Length.................... Total leaching area.---. __--__.__---_-sq. ft.
Seepage Pit No----- ---------- Diameter----f}_ ._ Depth below inlet.................... Total leaching . a..V40-----sq. ft.
z Other Distribution box (4) Dosing tank ( )
aPercolation Test Results Performed by---------------........................................................... Date.......................................
Test Pit No. I................minutes per inch Depth of Test Pit..------------------ Depth to ground water._--_--..__-_-.-_.-..._.
4, Test Pit No. 2................minutes per inch Depth of Test Pit.__--___-.________-- Depth to ground water------------------
G ---4_ - : . . I --------------------------------------------------------------------Description of Soil---------- le - ----- .v.....rt.1�....------ .
f - f
U ----------------------------------------------------------
f _�_�_ 7 /
-
UNature of Repairs or Alterations—Answer when applicable--------------------- d._ .".Z_ --=-------------.----------:....__--_--.--_. -
------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...... . --•------------------------------ �L..!-'7''l,•6ts
Date
Application Approved By----------- Ik Date
-•-•-- ` / ...7
((// Date
Application Disapproved for the following reasons:................................................................................................................
Date
PermitNo.......N.7... •---•---••-------------- Issued..................................-----------------•----
--
Date
----- ------------------------------- --------------------------- i'
L'
No.._-_._......................... Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ... ................OF.........................................................................................
Appliratiun -fur 43i.ipuuttl Works Tonutrurtiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
'`' =------------------------------------ ...------- ......................................................
LP
on ti -Address or Lot No.
� � c. ..... ..... ..(won.-----..._...._..------------- ...
W — Owner Add es
----------- ------- ----------------------------------------
Installer Address _ 7 U w)
d Type of Building Size Lot.... ......-------.......-Sq. feet
U Dwelling—No. of Bedrooms...-------f -----------------------------Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ------- ------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ---..---------
Q ------
Desi n Flow.............1.......--...._._.�!.�� 111on� per person per day. Total daily flow.._....._._-- b..�-._-.--.--.........--gallons.
W g g s P P P Y Y
WSeptic Tank—Liquid capacity- -gallons Length---------------- Width......-_....-.. Diameter-----_......... Depth----------------
x Disposal Trench— o--------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No......I .......... Diameter...- Depth below inlet____________________ Total leaching area...�/dQ----sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------- ----•-•-•---•------•••-••---- Date---------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........---------------.
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........--..-----.----.
O ........... ----- .--------------w-•-------• ---------•.........................................................
Description of Soil------------ - -P �-L)-'�-----I �t.e.....-----. /- a
x !_--- ------------------------------------------------------------------------
W -------------------------------------------------------••---------------------------------------------- ------------------------------------------------------------------------------------------
x ------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable...----.......................................................................................--
---------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------
Agreement: -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by he board of health.
,} Signed----/•^�-�-�~'f^' - -•--•0....-�:�-- ---------•--•-•---••------------- --- ---/.,fit.---��b
�,/ (,/ t / Date
ApplicationApproved BY ... /------`-------------------------------------------------------•-------------------- ---•-------1-•-� =L
f Date
Application Disapproved for the following reasons:-----•------•-••--•----------------•--•-•-----•-•-•-•-••--------..--...._..------..........._.._----.-__________
---•---...---•---------••--•-•----•-•-•--•--------------•-•----•----.......-•----------------------•---•----------•--------------•--•-----•---•--•-•----•-----•-------------------------- -------•-----
Date
PermitNo--------1 ..................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
G rr.l, �/plc ,S Y{p />C
OF.....................................................................................
%aprrtifiratr of f.111utphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by -------------•- ....... ..........
".41Installer
at T - '�f �G-T�
------------ -------------------------------------------------------------------------•-------------------------------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------- ..................... dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r O F ✓�i'�r: Ji> - /�U
.......:.......................................
r
FEE........................
DinVoml Workii Tonitrurtion Vamit
Permission is hereby granted--------- ----------•-----------------------------------•----------
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No. =r j---- f �-= /--------------s-'--•=----...----- 'G--=------`l�s�C, .��r G.....------.
Street x,
as shown on the application for Disposal Works Construction Permit No....---_-- .-----._ Dated---------------------� ! ?r
-----------------------------------------------------------............................................
-
Board of,Health
DATE-------------------------------------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
J
w �
April 1976
Board of health
town Of Barnstable
Attn, John Kelly, Agent
Dear Mr Kelly,
This letter is to verify that am having Clough & Cahoon
Well Drillers Inc. install a six inch casing well on my property
located at Cedar St West Barnstable, (Trailview)
I understand that Ir.'assume all responsiblity in being Issued
a wavier so as to inable me to secure a building permit at this
time.
I understand if the water is not determind usable per County
of Barnstable, I will not be allowed to occupy said dwelling until
such time that I have a negAtive report on said well.
John Owen
,. ,� - - ., - •,fir ,. f _ 1
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• ,t y i _"." „_ (R �.a y�GY E L._ �IdN !l Y C Mk. r LVIw)� •}'� - ^ y
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Box :c
_ h STOAT
i y,.y,N k 1000 . , , 1000 GAL �a►g� oSFAA!C
1
GAL.
� o PRECAST OR - .115.5f�!' � m
SEPTIC 1 6 , • - . 8"OCK -$tr
r, { ; TAME SEEPAGE PIT -
F%n e Sir 1
20 MINIMUM
• � � ` 4 4 _"�-'�e r •. �'_•- 0.{, �0- 1
FOUNDATION , t ` 1
i. 2. '1 '/z vVA S N E I? S TON
ELEVATION SKETCH PBRC. NAT¢ ,Less•6, V/1"C4 . i
SCALf TEST BY e4wtWA -Youp\j P.c-
�/ 1' T'OWh INSPECTOR PG.U) /� r'ro1
's l H4(I v •1)E OWE RAT OR JdN,, AQ 140
'f 5T MAOL ON ��'�i 7ro
�0°°90 n� o t�&WT&S STKS S4+ for Dive"mcr
GAT f j2 f�zi2� g9 i
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r� ZD�(��' 3s
tFoz� Lz' �' ,,\ � go N
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4t4' ' too/ \Z'�• • 6��s�'U •, � ` _
woo 0 A I�
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2 � 0 � .
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Q' 2
61
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6ro I Peoposeo I
~ q3 � o ecto 9B ti3 r\a9ar i�QJ'�;✓v �'�����tOA� " �
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e
. r - - sTtG��' - Ztiti �9(o-Zti x gg,o9 d0 • li
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APPROVED BY BOARD OF HEALTH, �5 ETIu��NG y
DATE,
E
OF
EDWIN A.
SUR
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ELEVATION SCHEDULE
PROPOSED S4TE PLAN
iX I I N V AT FOUNDATION = IZ2 , 00
SEWAGE SYSTEM DES161`!
2 1 NV INTO SEPTIC TANK = �21• �07 N
3 1 NV' OUT OF SEPTIC TANK (21 50 (3AQ S-rA BLE , MASS,
4 'Nb" INTO DISTRIBUTION sox 12. E SCALEqp AP2►L 1� 197
5 1 N V OUT OF DISTRIBUTION BOX = (2d. 3 .�'► 9 I
6 ,NV INTO SEEPAGE PIT _ ILO�SO CAPE 4OCi SURVF r CUNSUI TANTS
I
POLITE 132
7. BOTTOM OF PIT II q,So HYANN 5, MASS
A DIVI31GN 61031OM SURVEY, :.ON$ULTANTd,, •NC
B. BOTTOM OF STONE LAYER
I