HomeMy WebLinkAbout0072 CHURCH STREET - Health 72 Church Street
W. Barnstable P
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TO�lOFBARNSTABLE/4
Oki U re- '4- SEWAGE # ®�
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VILLAGE !9-d �6( r ny 4Q ke ASSESSOR'S MAP & LOT l-
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY. f U 0 9Q�
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
B OWNER V ►
PERMITDATE: COMPLIANCE DATE:
`separation Distance Between the:
Maximum Adjusted Groundwater Table and 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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TOWN OF BARNSTABLE
.LOCATION ' 711 SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL J S /u
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 5-60
�c
LEACHING FACILITY:(type) S (size)
NO.OF BEDROOMS
OWNER �A Sod SfeotY
PERMIT DATE; PI 1 jd COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. /J l A• Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) f;D 4n Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within l
300 feet of leaching facility) Feet
Feet .
FURNISHED BY 510 li A
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No. Fee r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye
2ppfitation for Disposal *pstrm Construction 3permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ,V Individual Components
Location Address or Lqt No � OO Owner's Name Address,and Tel.No. y'dv L37 3812
c ,- y Y / %JA00 s
As§essor's Map/Parcel -gA]W- A++
Installer's Name,Address,and Tel.No. esigner's Name,Address,and Tel 013
-10RgP, _ S4016W, C,cj �'o�36`�-�r oSALA - YaRn►�o�- 36z- �sy
Type of Building:
y�
Dwelling No.of Bedrooms p A Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) IV 11— gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soft
y Nature of Repairs or Alterations(Answer when applicable)
A no ct!i� �r�� �r� :rw c i 0 Q of TA✓ �
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signe Date /2.
` q
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 6-t Date Issued
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Y
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplitation for Disposal �&pstem ColletTurtion Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System JV Individual Components
Location Address or Lot No. / Owner's Name,Address,and Tel.No. r, ;+ ?
-'�' 0,07 a1.As-vN f?fir x
As essor s Map/Parcel y ,�.a;, i I et P0V- MA,
Installer's Name,Address,and Tel.No. �esigner's Name,Address,and Tel.No.
U.
Type of Building:
Dwelling No.of Bedrooms I Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of a_ :
Compliance has been issued by this Board of Health.
Signed & L . $ Date / 2. /1P
Application Approved by Date
... :::.
Application Disapproved by Date
for the following reasons
Permit No. ~ ' ! Date Issued
------------------------------------------------------ --------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
C.--►�,Q.- BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( ),by
at `7 7 c "1,v se w r 4k has been constructed in accordance c
/ with the provisions of Title 5 and the for Disposal System Construction Permit No c20 dated
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system{'will_fun .ion as\designed.
Date /� �J!�t Inspector\
---------------------------------------------------------------------------- ------ ------------------------------------- ------------
No. ?—0 f V
_ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Ne-posal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
/ \ System located at — 7 ? C �.� r,
m
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed wit in three years of the date of this permit. x' 1
Date 1 / Approved by j V
Invoice
Rusty's Inc. October 25, 2018
222 Mid-Tech Drive Summary: SERVICE
West Yarmouth, MA 02673 Invoice#: 5797-928663
508-776-1303 Tech: COREY H.
www.rustysine.com/info@rustysine.com Due Date: 11/24/2018
Job Date: 10/23/2018
Bill To: Job Name:
E2 Solar Inc Building
831 Main Street 72 Church Street
Dennis, MA 02638 West Barnstable, MA
(508)237-3892
Item Code Description Hrs/Qty Price Amount
Leak on pipe for building
Job Date 10/23/18: The old barn at 72 Church Street has NO plumbing, gas or water lines of any kind.
10/23/2018 Labor-Haddad 1.00 129.00 129.00
�i
Labor Subtotal Total
129.00 129.00 $129.00
All material is guaranteed to be as specified. All work to be completed in a professional manner
according to standard practices. Any alteration or deviation from above specifications involving extra
costs will be executed only upon written orders and will become an extra charge over and above the
estimate. All agreements contingent upon delays beyond our control. Purchaser agrees to pay all
costs of collection,including attorney's fees.
Terms: Due upon receipt
THANK YOU FOR YOUR BUSINESS
Commonwealth of Massachusetts /5y- 00
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots .r
Owner Owners Name
information is ='
required for every West Barnstable Ma 02668 11/8/2018
page. Citylrown State Zip Code Date of Inspection
s,,1
cat
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.
Imngoutforms A. Inspector Information
filling out forms
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Company
A Lane
Co
� Company Address
Centerville Ma 02632
City/Town State Zip Code
508-658-3456, 774-248-4850 SI 4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
11/8/2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 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 dwelling located at 72 Church St West Barnstable is served by a Title V septic system consisting
of a 1500 gallon septic tank, distribution box and 4 precast leaching galleys. The system was found
to be in proper working condition at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every Nest Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary(cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® 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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is West Barnstable Ma 02668 11/8/2018
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/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 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
i -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 p Y ►Y
�a
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leaks or blockages. Vented through roof
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gallons
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water'level was even with outlet, tank was not leaking and was structurally sound.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�. 72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�' le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every west Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. 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.):
Distribution box was level and in good condition with no rot. Water level was even with outlet invert
with no signs of past backup.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
1. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 4
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching facility was video inspected and found with 2' standing water and a stain line only slightly
higher.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every west Barnstable Ma 02668 11/8/2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
i
a �3
3 (4 23
(3 /57
A 2 33
2 z5-
�3 3 Y? fo
15insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 18
cam, Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. 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 established by accessing Town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated'depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Town Of ll��rustable --
afel and Environmental Services
Department of Ilcallh,S y,
Public HeIllith Division bate T
367 Main Sirect,I lynnnis MA 02601
! r ARNFIrrear.e. l
MAFK Pee Pd. 1��
0� Date Scheduled Time /c�•_ �Q.M�
Soil Suitability Assessment fof• Sewage Disposal
Q�cswG(i Ctr �� �G
Performed By:
Witnessed By:a�.Q-LY u�031A
ti
LOCATION & GENLRAL Yo FORMATTIIOr sy�vi�- y�oR.
Location Address L W L Oe_. jaNN �/')UI so�✓y�a�T��
L �L Address.
Assessor's Map/I'arcel: Engineer's Name A.(%W-A
NEW CONSTRUCTION REPAIR Telephone H U.2.+454
pp o Surface Stones 'frl�a
Land Used `.�ei" �� Slopes(/o) e
Distances from: Open Water Body N It Possible Wet Area _R Drinking Water Welln
R Property Line O n Other a
Drainage Way P y
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in p xlmity to holes)
y,0T
A-$15"7 f
l
Z°A
)so
G/7� u&
Parent material(geologic) S W\/ Depth to Bedrock
'/ Af
Ucpth to Groundwater. Standing Water in i iuie: N�`t' �'r==?'• from Pit Face —
Gstimaicd Seasonal Iligh Groundwater —
DETERMINATION TOIL SEASONAL IIICII WATER TAOLL
Method Used: dAA)f— �o� in. Depth to soil mottles: in.
Depth Observed standing in obs.hole: P
Depth to weeping from side of obs.hole-/� ___ in. Groundwater AdjusUncnt_ _R•
tilde.,(Well a_ •Reading Date:, Index Well Icvcl...___ Adj.factor Adj.Groundwater level_
PERCOLATION TEST
Observation Le 4 T4tc4A— Time at 9" 419aA^
I tole N
�.Aw� �,y�G>•r. Time at 6" *4-
Dcplh of Pcrc
xe-o r.e-..Pk Time ab Time(9"-6")
End Pre-conk
Rate Min./Inch
Site Suitability Assessment: Site Passed X1. _ Site Failed: Additional Testing Needed(Y/N)
Original: Public health Division Observation Bole Data To Be Completed on Back-j
Copy; Applicant
DEEP OBSERVATION HOLE LOG Hole t#
pcpth tPom Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure.Stones,Bouldcres.
;onsisicticv %Gravel)
YA
DEEP OBSERVATION HOLE LOG Hole# _
Dcpth front Soil Iforizon Soil Texture Soil Color Soil Uther
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stoncs,Aoul4eres•
K-(/z
Z.9c/ir Gy �•
No uJe� a Sas,
DEEP OBSiE;RVATION.HOLE TOG Hole#
Soil Texture .;oit Color Suil Other
Depth from ! Soil Hor)zor� �4unsclq B
(USDAi Moulin (Struc:wc,Stoncs,Ifoui•-res.
SurlaCti i,�..� �i iet n °' iravel�,—�
DEEP OBSERVATION ROLE LUG Hole#
Soil Texture Soil Color Soil Other
()cpih from Soil horizon (USDA) (Mansell) Mottling (Strucwre,Stones,Boulderes.
Surface(in) °� r
Flood Insut t=AA1L9=
Above 500 year flood boundary NO—
Within 500 year boundary No— Yes
Within 100 year flood boundary No— Yes
Delith of s Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material) _
Certification 0
1 certify that on (date) I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR )5.017.
Commonwealth of Massachusetts 15-y-00
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
,Q Company Address
Centerville Ma 02632
Cityrrown State Zip Code
508-658-3456, 774-248-4850 SI 4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
r that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails ---�
11/8/2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 72 Church St West Barnstable is served by a Title V septic system consisting
of a 1500 gallon septic tank, distribution box and 4 precast leaching galleys: The system was found
to be in proper working condition at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
i
Commonwealth f Mass
achusetts
sachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owners Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
f
Commonwealth of Massachusetts
ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
�9 Title 5 Official Inspection Form
<� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
0 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leaks or blockages. Vented through roof
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gallons
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness 211
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
f
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
In Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
j' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
'8. Tight or Holding Tank(cont.)
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
0. 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.):
Distribution box was level and in good condition with no rot. Water level was even with outlet invert
with no signs of past backup.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
tl4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number:
4
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching facility was video inspected and found with 2' standing water and a stain line only slightly
higher.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
V
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:.
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
Z2
D � ,
/3 ( ( 23
3t /5
,A 2. 33
2 Z5-
i3 3 Y� fo
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is required for every West Barnstable Ma 02668 11/8/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. 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 established by accessing Town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Church Street
Property Address
Jason Stoots
Owner Owner's Name
information is West Barnstable Ma 02668 11/8/2018
required for every
page. Cityrrown State Zip Code Date of Inspection
,E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
COMMONWEALTH OF MASSACHUSETTS
N w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
oW
IVAP PARCEL--.�®
TITLE 5
`Q7 l
1—
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM 7ww
255
PART A ECEIVE
CERTIFICATION
4
Property Address: 72 Church Street
West Barnstable MA 02668
Owner's Name: Sheila Sylvia
Owner's Address: Same
Date of Inspection: April 21,2004
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection: The inspection was performed based on m
training and experience in the proper function and maintenance of on site sewage disposal systems. I am`��tOFl �/
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ;�� .s•��...•..;�•
XX_ Passes ••yG
— Conditionally Passes TR1 u'
Needs Further Evaluation by the Local Approving Authority 0
Fails NEL
Inspector's Signature: --- ��==� Date: _4/21/04� ,FS fNSPEGo��.
11allu�ta�
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments: Observed one foot standing water in four foot high galleys.
****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.
Title 5 Inspection Form 6/15/2000 page 1
t
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 Church Street,West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 21,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ 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:
P
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y„N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
ass in
spection nspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
I
Page 3 of l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Church Street,West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 21,2004
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(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
T The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is fi-ee fi-om pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Church Street,West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 2.1,2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
—X—
Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
_ —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
_X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
__No_(Yes1No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 Church Street,West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 21,2004
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ — Pumping information was provided by the owner,occupant, or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection'?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ — Was the facility or dwelling inspected for signs of sewage back up ?
_X_ _ Was the site inspected for signs of break out'?
_X_ _ Were all system components,excluding the SAS, located on site?
_X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of
scum '?
_X_ __ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
_X_ _ Existing information. For example, a plan at the Board of Health.
_X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 Church Street,West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 21,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): N/A well water
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMM ERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):_
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Tank pumped 2-3 years ago
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If es volume um ed: Qallo -
Y p p _gallons - How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Compliance date: 7/14/89
Were sewage odors detected when arriving at the site(yes or no): No
Page 7ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Church Street,West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 21,2004
BUILDING SEWER: X (locate on site plan)
Depth below grade: l'
Materials of construction:_X_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line: 45'
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: X (locate on site plan)
Depth below grade: V
Material of construction:—X—concrete_metal_fiberglass_polyethylene
--other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10.5' long x 5.8'wide—1500 gal.
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle:24"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 11"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Tees intact and clear.liquid level at bottom of outlet pipe
GREASE TRAP: No (locate on site plan)
Depth below grade:Material of constructi—
on:_concrete—metal_fiberglass_polyethylene,other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
I
Page 8 of it 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Church Street,West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 21,2004
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: _gallons/day
Alarm present(yes or no):
Alarm level:_ Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: X (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.):
Box set level,one outlet pine
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Church Street,West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 21,2004
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
_X_leaching galleries,number: Four 4x4 galleys.
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.): Observed one foot standing water with no high stains
CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth--top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
Page ]0 of 1]
OFFICIAL INSPECTION FORM—NOT FR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL S STEM INSPECTION FORM ASSESSMENTS
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Church Street, West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 21,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Church Street
O
lao'..p
I
z3 I
i
3`I
f
Page I I of 1
OFFICIAL INSPECTION FORM[-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Church Street,West Barnstable
Owner: Sheila Sylvia
Date of Inspection: April 21,2004
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow well's None
Estimated depth to ground water: More than 20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el.30 and topo map shows property above el.50.
TOWN OF:SARNSTA3LE
LO ATIO'. �„� y��'� 4� SEWAGE 3
VILLAGE (� - GCS ASSESSOR'S MAP & LOT 5� C
J. E. KENNEDY TRUCKING
INSTA'LkI +'S NAME Ci PHONE NO. 575 WILLOW STREET
WEST BARNSTABLF MASS. 0266dAd
)"iSEPTIC`T. A'.K CAPACITY ,,,�� /SD
-U_6 ays-avert
.EACHING FACILITY:(t7pe) (size)
MNO. OF atftOOMS_ PRIVATE WELL OR PUBLIC WATER_���121
._BUILDER OR OWNER ,
DA7-E.PERMIT ISSUED:
r: X
TE i COESPLIA.NCE IS SUED: - ! -
VARIANCE GRANTED: Yes No �
oS
fk
k �
� B 2
S9 ''
....:=:2.� FEs... :.
\ THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
OF..........
..............................----------- .................................
Appliration for Disposal Works Toostrurtioo ramit
Application is hereby made for a Permit to Construct ( ) or Repair Y ) an Individual Sewage Disposal
System at:
... ... ........................................ --• •-•-------•- -.._.0..........................................
Localeetf�idd s or Lot No.
.............. �.u. s------------------------.... .......------------.._...----------------- ---- --------....._..........---------.........-----
O ner Address
a --•.......................... V.I." _.. .. __.............____------------------•-
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling=No. of Bedrooms.... ................................Expansion Attic ( ) Garbage Grinder ( )
`44 4 Other—T e of Building No. of persons__________________•-____-___ Showers — Cafeteria
dOther fixtures ...........................................0..........................................................................................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth............_..
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area..........__-.......sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-••••-•-•------------------------•-•-----•--•-•--•----------------•-••--•-------------..._..................................................................
0 Description of Soil_._ . ,
x
U ------•--..._..---•--•----------•••--•------•-•----..__...••---•••••--••-------•...............•---•••••---••-•-----•----••-•-•••-•------•--....-•••---•--••----------•-•---------------••--------•-----
W
U Nature of Repairs or Alterations—Answer when applicable.---------------------------------------------------------------------------•-_-______-_-_-.•__.
------------------------•-••-•••-----•-------•-......-••--••-----•--•-•-------••---------...........•----------•-------------•------••--••-•--•-•---•-•-••--•--•-•-•-•---••--•---••--•-••---•---------•-
Agreement:
The undersigned agrees to install the aforedeseribed Individual Sewage Disposal System in accordance with
the provisions of iITiE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed ----••. t
:,
Date
Application Approved BY---••--- ---- = - --!-___ --•--------•---••------•-••-
-..
........................................
Application Disapproved for the following reasons--------------------------------------------- ----------------------------------------------------------------
............................................................-............................................................................................................................................
11,.� Date
PermitNo.. ............ �.. ........ Issued-------................................................
Date
No. �......3 c�.............
....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.................:....-........1 rt---•--..............................................
ApplirFa#ion for Dispnsal Works Tomitrnrtion thrmit
Application is hereby made for a Permit to Construct ( ) or Repair kv) an Individual Sewage Disposal
System at:
71
..........•--•--...•...---•--_•---.....----•............................... � :....__._...-] �:,
Locatiofi•'Adds 9s or Lot No.
✓ : cS
---••--•-------•................•.••-------.....-----....•....-•---•........................•..... ..............•••-•-••---••-••-............---._......._......-•-•--...........••••...••..........
ner t Address
1......................................C >�Tl;t -ii
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling No. of Bedrooms___- ................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
P.I YP g ---------------------------- P Cafeteria ( )
p' Other fixtures ................................. .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity........____gallons Length................ Width................ Diameter---------------- Depih................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------------•--- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
L=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---•••-•--••••--••--••-•-•••••-••••----•....•-••-•••-••-•---•-••••-•-••-•--••-•...-•------•-------------•--•--------•--•---•••-•-•......------•--••---•....--
ODescription of Soil...: p ...------•----------------••---------------•---.....------------------------------------•-------------------------------------••--.......---
W
V ....••--•-••-••--•••-••--•-•••••-••---••--•-••--••-•-••---•-•---•••--•••--•-••-•-••-•••-••---•-----•-•-•••--•••-••-•-•------••-•-•......-••-•-••-
W
----------------•-------------------------------------.......--------------......----...---------------------------.....------...------...-----------------------------------------------------.......
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 T IT LZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
_ Signed....................
=................................................................ ................................
Application Approved By....... __.. -rl
Date
---•-------...
Date
Application Disapproved for the following reasons:.................................................... _
.....................•------•_. ----------....
--------•-•----------•--•----•--------•--•---------------•-•--•------------------............--------------•---•••--•-•---------••----- •---•---•-••---•-••---•-••--••••-•--•-•-----•--•-••------.......
�----� Date
PermitNo.. ....t �......--•----•-...... Issued---------------••-•-•------••--••---•................- --------•--------
Date
THE COMMONWEALTH OF MASSACHUSETTS
r� - --- BOARD OF HEALTH
..............�:s:..................OF...................................................I.................................
Trrfifiratr of Toutphattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at---------------------------------------•--------•---•----------....-----•---.........---•------------------------•-----------•-----------------•-----•--•----------------------------•----•----------
has been installed in accordance with the provisions of 11"I71-Z 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ",/ -.- -.... Inspector--••---------. _ ....................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' � f
No...:........ ........... FEE........:._.............
Disposal WorkpOunstrurtion rrntit
Permission is hereby granted.. —�1- C c`�
-• ------ ....
to Construct ( or Repair ( )r an Ind -i.dual Sewage Disposal System f
atNo...................... .......................................................N J ✓ . 1-Q_—..................I........ �..
Street .,)" t ).f /
as shown on the application for Disposal Works Construction Permit Dated....... < ..
------••--•••--•-•--••••-•-••----••-•--••----•-••-------•-•-•••••-----•-----•••••••-••----••......•••-•-
-�° .......................................... Board of Health
DATE........ --f-=�-- ----•---�.1
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0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675
8-451