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Home My WebLink About0302 CHURCH STREET - Health 302 Church-St. (W.oBarnstable) A= - f zl� 4 .,, Pate No... .. Fss. THE COMMONWEALTH OF MASSACHW ETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Applira#ion for Disposal Works Tons t Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: .............. ........................� ----.......----.. -------- ��..... ....................................... �Locati Addre or Lot No. ....... .............:� ---- _ . .. -- ._ .-. . . Owner A" It s � /J P- - ..:: ( r��..................... ............. :. �= ---4 ... j �U---------- 14 Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.__..3..................................Expansion Attic ( ) Garbage Grinder ( ) a e of Building a Other—T yp g ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures - W Design Flow..._._..:5 .-................gallons per person per day. Total daily flow_._.._._.....�.-�-D---....................gallons. W Septic Tank-L Liquid capacitXC��gallons Length-----�..____ Width---�_..... Diameter................ Depth................ x Disposal Trench—No................._... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No____________________ Diameter....\.-_......_. Depth below inlet__..L............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ 0 Ri ...-•-•---------------------------------•--•-••----------...----....----._...------.......................................................................... Description of Soil........................................................................................................................................................................ W V --------------------------•---------------••-----------------------.....----------•-------•-•••-----••---------------------------------...----•-•-•-----•-----------------••••......-•--------•---•--.-- W U Nature of Repairs or Alterations—Answer when applicable... __._..1.CFIXL3... -_..grpxC _ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issu-_ed by the bo rd of health. _ Signed`....... -........ . �. �1 ..... -------------------- --- Dale ApplicationApproved By - -- ----- - -------- ------------------------- --- ........... - . . ---------- . ....................... ....------ ---....................... Application Disapproved for the following reason - ........................................................................--------------------- ------------------- --------------------- ------------ ----------------------------- Date Permit No. �.......... .. .. ....-L'� ---------------------- Issued e j 153 _ No.... FEic...... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE } Appfiration for Dtiipniial Workii Tomitrt(rfivn .rruttt Application is hereby made for a Permit to Construct ( ) or Repair ( 1 an Individual Sewage Disposal t System at: t Locatio -Addres or Lot No. .. /cam W?5:...........- Owner Address. C Q: �. ��,-� ..Jc/Cc - -••- ---...................................................I(__ /11 Installer Address., UType of Building ej Size Lot............................Sq. feet Dwelling—No. of Bedrooms....",5.................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons..................................... Showers ( ) — Cafeteria ( ) P 1 Other fixtures ------------------------- ............................ W Design Flow.......... ._..._.�'�_•________________gallons per person per day. Total daily flow---_-__----5---3•_--------_................gallons. Septic Tank—Liquid capacityVldtgallons Length-___-�_.._.. Width._•'. ...... Diameter_____________ _ Depth................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. % Seepage Pit No------1-------------- Diameter-__--t n..._.... 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........................ 4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -••••----•----------•--•-•...----••-••---••--••-••-••••-•----•-.....•••••-•-•-•..........•-•......................••--•-••••-•-•......-•--------•..........-- 0 Description of Soil....................................................................................................................................................................... W W U •-----------------•--------•----------------------••--••----------•-------------•----•------•----------••------------------•-------- •------------------- •------------------------------- .--------------- U Nature of Re(pAairs or Alltterati/o�ns—Answer when_applicaabble._ ..�. �� _"j�.�.��------k rn�..._-?'�?t�. v-`tt_..............,?--:..!-=_.LY..........!!:.+ -.K:____ =`-_.__ -;. .,.__.:!.`.Cf''t- '........................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. g ✓ ..Sl ned ........ ---j - -- .. ... -o - �/ Date ApplicationApproved By ... -� .. .. -d' _ .....----�..................... -------------------------------------- Date Application Disapproved for the following reason - ---........................... -------------------------------------- -----------................................................. ---------- - ------------------- ----- ......Da t �f Date Permit No. --- 7 Issued ............. e...`.". ... ------........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gerttfi ate of C rapttttnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ....... +:.�a..P... ... .. .n-..-...-. -.r----------------.................................................................................................................... 9 Installerat ...................................... z -....-_tf_ - ,�J - - has been installed in accordance with the provisions of TITLE 5VO he St Z onmental'Code as described in the application for Disposal Works Construction Permit No. .. . dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BNS UED S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... - .. ..` .. Inspector .. �`�.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.�t... ....... FEE......... ............ Utopoiial Iforkii Tomitrudion anttt Permission is hereby granted.......... -•Se-f ,_C.................. to Construct ( ) or Repair ( #..-)-•ati Individual Sewage Disposal_System at re ..................................... ----------•-- Street as shown on the application for Disposal Works Constructioil�exmit No...f.__._ _ .. / .2.... at •�•••.. i1.A— -- -------- - ------------ Boa Health DATE................ ---•-------••---------- I ' FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS I53-oo9- o�� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St rM Property Address David Driscoll Owner Owners Name -a �y West Barnstable ✓ MA 02668 202017 Pam, otyfrown State Zip Code Date of InspecWn � sa Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Pleam see completeness checklist at the end of the form. fi16 foV A. General Information v�l # la/3$ on the computer, use ony the tab 1. Inspector key to move your cursor-do not Paul Martin use the return Name of Inspector key. - Cape Cod Septic Services Compm Nam 350 Main St Company Address W.Yarmoutlt MA 02673 CILyfrown State Zip Code 508-775-2825 S15016, TeWtone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector.pursuant to Section 1&340 of 'Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2R/2017 inspeatoes Signature. Date The system inspector.shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shah submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner A and copies sent to the buyer,if applicable,and the approving authority. """This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. h: 15ins•3/13 To 5 Offidal Irwpadion Form SWMrface Sewage Disposal System• 1 of 17� µ A D Commonwealth of Massachusetts NCEMEM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St Property Address David Driscoll Owner Owner's Name i"rO°M1m is West Barnstable MA 02668 2/2/2017 required for every Cityrrown State Zip Code Date of Inspection Paw- B. Certification (cunt.) Inspection Summary.Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: Sgtem in working condition B) System Conditionally Passes: ❑ One or more system components as described in the"Condifional 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 exfittration or flank 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): tbfns-3113 Title 5 0111dal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St PM"Address David Driscoll Owner owners Name informafion is for emy West Barnstable MA 02668 2i?J2017 mquhwper- Cityff"n state Zip code Date of Impettion B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt): ❑ 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 wilt pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if -the system is failing to protect public health,safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 1254iw.$1`13 Title 5 Official Uispection Form:Subsurtace Sewage Disposal System•Page 3 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St Property Address David Driscoll Owner Owner's Name rrationedfo a required for West Barnstable MA 02668 2=017 r every page. Citylrown State Zip Code Date of kgmc ion B. Certification (cunt.) 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- El 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 cerdfled laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No 0 ® Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded, or dogged SAS or cesspool _ ❑ ® Liquid depth in cesspool is less than 6'below invert or available volume is less than%day flow t5ais•3M3 TUB 5 Otfial Inspection Form:Substsfaee Sewage Disposal System•Page 4 d 17 Commonwealth of Massachuseti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St Property Address David Driscoll Owner Owners Name informadon is west Barnstable MA 02668 2/2/2017 requires for page- citylrown State Zip code Date of Impec6on B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes°or'no"to each of the following, in addition to the questions in Section D. Yes No ❑, : ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection ❑ Area-1WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes'to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department t5ins•3f13 Title 5 Official kspecbon Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 302 Church St Property Address David Driscoll Owner Owner's Name information isrequir fo West Barnstable MA 02668 2=017 required r every Pap- Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as WA) ® ❑ 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 bafftes or bees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design).' 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330gpd 110pd t5ins•3M3 Title 5 Official Mspec ion Forth:Subsob a sevmpe Dish System•Page 6 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St. Piroperty Address David Driscoll Owner Owner's Nam d on is required West Barnstable MA 02668 2/2/2017 �� ems+ Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection El 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)): N/A Well Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Curren t� CommerciaUlndustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): . Gauons per day W Basis of design flow(seaWpersons/sq.t, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3M3 Title 5 Official MWSOM Fan Sftuface Sewage Disp and System•Wage 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St Property Address David Driscoll Owner Owner's Nam information�y West Barnstable MA 02668 2I2�2017 pW- City/Town State Zip Code Date of Inspection D. System Information (corn.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information; No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: How was quantity pumped determined? Reason for pumping: Type of gym: Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overllow`cesspoot Privy ❑ Shared system(yes or'no)(if yes,attach previous inspection records, if any) E ' Innowative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract t. Tight tank.Attach a copy of the DEP approval. Other(describe): t5ins o 3113�a Title 5 MOW Form:Subsurface Smape Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St Property Address David Driscoll Owner Owner's Name required equir df r everyis West Barnstable MA 02668 2/=017 pap. Cityrrown State Zip Code Date of Inspection D. System Information (cone.) Approximate age of all components,date installed(if known)and source of information: 1992 Per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 29' N Depth below grade: teat Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from.private water supply well or suction line: +10' feet Comments(on condition of joints,venting,evidence of leakage,etc.): Line checked with sewer camerra and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade., 12„ rfeet Material of construction: ®concrete 'k ❑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 ' r4. 16000ai Dimensions: Sludge depth: 6" •:3H3 TWOS OW001 bWaction Form:Butane Sewage Disposal system`page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fong-Not for Voluntary Assessments 302 Church St PrWdy Address David Driscoll Owner Owner's Name tnf°m'ation is West Barnstable MA 02668 2=017 pa page- City/Town State Zip Code Date of InspecfiOn D. System Information (coot.) Septic Tank(cost) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 3-T Distance from top of scum to flop of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 1500Gal tank n good structural condition. PVC tees in place.Tank at normal operating level. Covers 12"below grade. Recommend service of tank Grease Trap(kocate on site plan): Depth below grade: teat Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene . ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3M 3 Title 5 Offic al 6tspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts WRIEW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St. Propwty Address David Driscoll owner Owner's Name information is West Barnstable MA 02668 2=017 required for every City/Town State Zip Code Date of Inspection D. System Information (corn.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Offnal bspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St Property Address David Driscoll Owner Owner's Name hibmation is required for every West Bamstable MA 02668 2=017 Page- Cityrrown State Zip Code Daft of Iran D. System Information (corn:) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert . 0" Comments(noted box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): H-10 Db-3 with 1 line in and 1 line out in good condition. Box is level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 18"below grade. 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. Soft Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: L%is-3M3 Title 5 Official h9pecUM Foam subadaoe sewage Disposal system-Page 12 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St. Property Address David Driscoll Owner Owner's Name 1b is West Barnstable MA 02668 2/2/2017 reqump every ChyRo Stele Zip Code Date of IWO 60n D. System Information (corn.) Type: ❑ wing pig number. ® leaching chambers number. 5-Infiltrators ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): 5-Hi Cap Infiltrators with stone in a 10'x30'Trench.2"of effluent found in units at time of inspection. No sign of overloading or hydraulic failure Cesspools(cesspool must be pumped as part of inspection)(locate on site plan). Number and configuration Depth—top of liquid to inlet invert a Depth of solids layer r Depth of scum layer Dimensions of cesspool . Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ft•3113 Title 5 MOM kgnMw Fomc&"wfwa SwW System-Page 13 of 17 4. Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Fort-Not for Voluntary Assessments 302 Church St Property Address David Driscoll Owner Owner's Name required for every West Barnstable MA 02668 2IM017 r for per. Citylrown State Lip Code Date of irtspt� D. System Information (corn.) Comments(rote condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•3113 rile 5 offiaal hspecbw Form:Subsufaoe sewage Dispc s System•Page 14 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 302 Church St. Property Address David Driscoll owner owner's Name frrfonnation is West Barnstable MA 02668 2=017 required for every CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below. ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Forth:SLdmK a Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St Property Address David Driscoll Owner Owner's Name rr�na>mn isuired fiDr every West Barnstable MA 02668 2=017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth l o high ground water. +10' 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: 1992 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: Test hole to 19 with no water encountered.Max bottom of leaching at C. Wore fling this Inspection Report,please see Report Completeness Checklist on next page. t5Rw•3H3 Title 5 OFfid81 Form:Sttbstsfaoe Serge Disposal system•Pape 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 302 Church St. Property Addnss David Driscoll Owner Ownees Name i dbffnawn is West Barnstable MA 02668 2=017 required for every page- wn CiWTo State Tap Code daft of IW4X ti E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)Completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins%W13 Title 5 Olfidal krepeebw Foffrr S ibsrefaos Sewage Disposal System•Page W or 17 TOWN OF BARNSTABLE LOCATION r�c.r, Sr SEWAGE # 9- oZ37 U/� /33-Eb9 l VILLAGE (y,, AwK.sq k ASSESSOR'S MAP& LOT INSTALLER'S NAME 6s PHONE NO._C"1 14 JOrl LsAO,6 SEPTIC TANK CAPACITY_ 1 LEACI ING FACILITY:(type)Z 1 LT(ZaT6i2 tsize) 3�x/0` NO.OF BEDROOMS ATE WELLPUBLIC WATER BUILDER OR OWNER "T'db 141^f fnn�(-5:S,-0 DATE PERMIT ISSUED: 6?1 , IT;?. DATE COMPLIANCE ISSUED: - d�-0l - / VARIANCE GRANTED: Yes No +� 15d a f 4(. s- �� 2 g 37 TOWN OF BARNSTABLE #O LOCATION 30')� G v� SEWAGE /# 9— 0-37 VILLAGE AfZX-5Itcb- ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY I 'j `�8 vV LEACHING FACILITY:(type) (size) X�K/t)e NO. OF BEDROOMS �- ATE WEL PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No cwryry� 15d 6 � ¢( ;a Al COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVE® WON IVIAH 3 0 2001 e ',gin TOWN OF BARNSTABLE HEALTH DEPT. '' TITLE 5kw OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM : s PART A CERTIFICATION l Property Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 M1 I PI LI ;a Owner's Name: MR.POLA I Owner's Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 Date of Inspection: 3/26/01 i Name of.Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: /,P 10. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is { true,accurate and complete as of the,time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systern: , X Passes t _ Conditionally Passes _ Needs Fu r Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3/26/01 The system inspector shall subm 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 ti sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V.7NPECTION. RECOMMEND PUMPING THE EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ; ****This report only describes conditions at the time of inspection and under the conditions of use at that time.'Phisr. inspection does not address how.the system will perform in the future under the same or different conditions of use. , . t i Titla 5 IncnPrtinn Fnrm 6/15/1000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS « +. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) _. Property Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 M111 P11 Ll Owner: MR.POLA Date of Inspection: 3/26/01 �. b a Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D „$, A. System Passes: f . X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: ' THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: r ,i _ One or more system components-as described in the"Conditional Pass"section need to be replaced or repaired.The system, 11.111Alo upon completion of the replacement or repair,as approved by the Board of Health,will pass. r ;; Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. " a n/:a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits ; substantial infiltration or 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. s'. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed , pipe(s)or due to a broken,settled''or uneven distribution box. System will pass inspection if(with approval of Board of Health): ;,r _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a ' n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a a y€; i t7 + .i Page 3 of 11 w,p OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS r ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 302 CHURCH'ST WEST BARNSTABLE,MA 02668 M I I I PI Ll Owner: MR.POLA Date of Inspection: 3/26/01 C. Further Evaluation is Required.,by the Board of Health: r _ 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(I)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: `'a�' _ 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 r 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. k _ The system has a septiOtan06d 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 n/a "This system asses if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and Y P Y ,P rY, 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 ,F of the analysis must be attached to this form. 0 3. Other: n/a I Z Page 4 of 11 �yjf.4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART A . CERTIFICATION(continued) ;> Property Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 M111 PI Ll Owner: MR.POLA Date of Inspection: 3/26/01 : ,tl1 D. System Failure Criteria applicable to all systems: a t You must indicate"yes"or"no"to each of the following for all-inspections: ections: Y g P 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'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times lu pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool orprivy 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 butgreater 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 k,N*V less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be ,+,iF,. attached to this form.] e� C` (Yes/No)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: Y To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. r You must indicate either"yes"or"no"to each of the following: f (The following criteria apply to large'systems in addition to the criteria above) .Vrc; yes no X the system is within 400 feet of a surface drinking water supply X the system is within 260 feet'of a tributary to a surface drinking water supply Y •aY�: X the system is located in a`nitrogen sensitive area Interim Wellhead Protection Area—IWPA or a mapped Zone II of a public water `supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threats 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. 11 Page 5 of i l ti OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 MI II PI LI ; P Y Owner: MR.POLA Date of Inspection: 3/26/01 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 r ;tri 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 ? r ;^ X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ' R X _ Was the facility or dwelling inspected for signs of sewage back up? y 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? t 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: >;r • f Yes no r� s 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)] • t lt`i1 U; t a S 5 Page'6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 M1II PI LI Owner: MR.POLA Date of Inspection: 3/26/01 FLOW CONDITIONS 13 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 inspectioA required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO ` Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.20,3): n/agpd Basis of design flow(seats/persons/sgfl,etc.): n/a Grease trap present(yes or no): NO f Industrial waste holding tank present(yesor no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a r� GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a 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) _x fight tank Attach a copy of„the DEP approval t f Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: . 1992 PERMIT 92-237 Were sewage odors detected when arriving at the site(yes or no): NO h Pcge 7 of 11 '4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART C SYSTEM INFORMATION(continued) Property Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 M1I I PI LI Owner: MR.POLA Date of Inspection: 3/26/01 BUILDING SEWER(locate on site plan) 1_+ Depth below grade: 12" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,,venting,evidence of leakage,etc.): h THE WELL IS 100+FEET TO SYSTEM SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a . g. If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10'6" H 5'6" W 5' 8"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 0" 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: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING EVERY TWO YEARS TO PROWNG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a l ; Material of construction: concrete metal_fiberglass_polyethylene_other(explain): n/a L '" Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a \' 7 f. f Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �j5 1 SYSTEM INFORMATION(continued) '= Property Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 M111 P11 Ll Owner: MR.POLA Date of Inspection: 3/26/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions:n/a tip, Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A ; Alarm level:N/A Alarm in working order(yes or no): NO `{ Dare of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if presenf must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): NONE , r � E PUMP CHAMBER:_(locate on site plan) i' } Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): ; ,> n/a. � 7 Sri.c; .i I a. R Q Page 9 of 11 f? , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .A SYSTEM INFORMATION(continued) Property Address: 302-CHURCH ST WEST BARNSTABLE,MA 02668 M111 Pl l Ll Owner: MR.POLA Date of Inspection: 3/26/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a r,t �a Type n/a leaching pits, number: n/a a INFULTRATORS leaching chambers, number: 5 ��t ,kit 4 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a r a n/a leaching fields, number: n/a overflow cesspool, number: n/a innovative/alternative system Type/name of technology: n/a ' Comments(note condition of soil,signs of hydraulic.failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE. i CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a 's`r Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): #14• n/a ' .. PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM INFORMATION(continued) Property Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 M I I I PI LI Owner: MR.POLA Date of Inspection: 3/26/01 SKETCH OF SEWAGE DISPOSAL SYSTEM i 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. , � g D�k c R. 5 G�5e AA Ae- aD RA 8 T c.R 3� Cg 41 cc 2� 6 Y in ti Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 302 CHURCH ST WEST BARNSTABLE,MA 02668 Mill PI Ll Owner: MR.POLA Date of Inspection: 3/26./01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 10+FEET 11 -�Q Z CiG S`L 7 O-O or- ug/J 671C'/d� i