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Home My WebLink About0057 CROCKER ROAD - Health 57 CROCKER ROAD, W. BARNSTABLE A= 109 040 %r a U d i Y J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris owner Owner's Name information is West Barnstable MA 02668 February 7 2014 required for every ry page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the.form. important:When A. General Information filling out forms on the computer, O� use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of inspector key. - Eco-Tech Environmental Company Name VQ P.O. Box 1265 Company Address West Chatham MA 02638 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I.certify that l have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: . ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority February 7, 2014 Inspectors Signature Date The system inspector:shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30:days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the.conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. VV. I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 A, r Commonwealth of Massachusetts mum. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Syr< 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7, 2014 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of garbage grinder is recommended B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as'approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of'17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M , 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7 2014 required for every rY , page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The systems required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7, 2014 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7, 2014 required for every rY page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7, 2014 required for every page. 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•''r 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7 2014 required for every rY page. City/Town State Zip Code Date of Inspection D. System Information Description: Original system was installed by Norman Ayotte in 1976 (Permit#76-50).System was upgraded by Hickey Construction in 1993 (Permit#93-194)with no plan required by the Barnstable Health Department. Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage n/a 9 ( Y 9 (gPd))� Detail: n/a-well in use Sump pump? ❑ Yes ® No Last date of occupancy: 3 weeks ago Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i r Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is required for every West Barnstable MA 02668 February 7, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner's agent Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): Septic tank and two leach pits in series. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts 4 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7, 2014 required for every rY page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20+ years. Certificate of Compliance for new leach pit issued 5/4/1993 (Permit#93-194). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Sewer lines appear structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1 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: 8.5 x 5 x 6-1000 gallon Sludge depth: 9 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is required for every West Barnstable MA 02668 February 7, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 25 in Scum thickness trace Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time. Maintenance pumping is recommended within 2 years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is rY West Barnstable MA 02668 February 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is required for every West Barnstable MA 02668 February 7, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Crocker Road Assessors Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7, 2014 required.for every rY page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ Reaching 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.): Soils above leaching pits appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Overflow leach pit was uncovered and was empty and dry. No staining at cover interface or in overlying soils was observed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7, 2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts G r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °y 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7, 2014 required for every ry page. Citylrown 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 PET CH PET CH LOOCA IO S 2 -OF SEPTIC COMPONENTS -DISTANCES IN DECIMAL FEET A 8 1 36 28 I 2 70 74.5 1000 GALLON SEPTIC TANK B A THIS ETCH IS E X TING BEST VIEW D IN DWELLING ELLING COLOR FORMAT 57 Q ¢ p 'ol Ui OQ 3 W CA 508 364-0894 aP C ROo C�G�ER ROAD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 57 Crocker Road Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is West Barnstable MA 02668 February 7, 2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 50+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Town of Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 50 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form Not for Voluntary Assessments 57 Crocker Road. Assessor's Map 109 Parcel 40 Property Address Timothy and Barbara Kris Owner Owner's Name information is required for every West Barnstable MA 02668 February 7, 2014 page.. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C,D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information_ Estimated depth to high groundwater ® Sketch.of Sewage.Disposal System either drawn.on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE - NOT TO SCALE + irPRECAST , LEACH41 . PIT BOTTOM OF LEACHING PIT LEACHING IS ABOVE HIGH GROUNDWATER GROUNDWATER ELEVATION PER GIS .MAPS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 JOB# 3767 LOCUS 22 Luscombe Lane Sandwich Setup#1 Gun @ SPK-1 hi= 4.95 0 on SPK-2 El PK-1 137.50 Deg Min Sec =>HMS Dist +- Hp Descr X Y Z 0 0 360.00 133.600 2.55 5.5 SPK-2 133.600 0.000 139.50 101 29 40 258.51 18.360 4.89 CB-5 -3.657 -17.992 137.56 37 35 322.42 26.410 4.89 WELL 20.929 -16.108 137.56 36 5 45 323.91 123.520 4.89 CB-6 99.815 -72.762 137.56 16 47 343.22 243.770 4.89 WELL 233.386 -70.389 137.56 18 8 341.87 121.850 0.58 4.89 EOP 115.798 -37.923 138.14 1 17 358.72 73.990 0.12 4.89 EOP 73.971 -1.657 137.68 331 22 28.63 53.450 -0.11 4.89 EOP 46.913 25.613 137.45 311 25 48.58 64.670 -0.29 4.89 EOP 42.781 48.497 137.27 312 1 47.98 105.460 -0.07 4.89 EOP 70.589 78.352 137.49 312 12 47.80 152.690, 0.06 4.89 EOP 102.565 113.113 137.62 311 53 48.12 215.420 0.58 4.89 EO,PDW 143.818 160.381 138.14 311 37 48.38 233.680 0.76 4.89 EOPDW 155.197 174.700 138.32 310 59 49.02 262.450 0.91 4.89 EOP 172.125 198.124 138.47 Setup#2 Gun @ SPK-2 hi= 5.090 4.87 5.280 0 on SPK-1 El SPK-2 139.500 Deg Min Sec =>HMS Dist +- Hp Descr X Y Z 0 0 0 540.00 133.600 -2.10 5 SPK-1 0.000 0.000 137.49 129 10 45 410.83 93.070 0.00 5 SPK-3 192.390 72.151 139.59 29 7 510.88 34.010 0.10 5 L 103.888 16.549 139.69 129 10 45 410.83 93.070 0.25 4.67 SPK-3 192.390 72.151 139.95 147 24 392.60 40.360 -1.21 3.55 L 167.601 21.745 139.61 181 13 358.78 18.700 -1.19 3.55 FL 152.296 -0.397 139.63 67 54 472.10 64.050 -0.04 4.67 18-0 109.503 59.344 139.66 91 59 5 448.02 61.430 1.57 4.67 HC-10 135.727 61.393' 141.27 83 35 456.42 74.970 -0.42 3.5 L 125.222 74.500 140.45 104 26 435.57 36.480 -0.69 3.5 CSTP 142.693 35.329 140.18 82 6 457.90 18.370 -1.13 4.67 L 131.075 18.196 138.57 90 46 449.23 106.170 -1.34 3.5 L 135.021 106.160 139.53 71 0 469.00 101.440 -0.66 4.67 WG 100.574 95.913 139.04 32 28 507.53 16.03 -0.43 4.89 12-0 120.075 8.605 139.46 51 55 488.08 30.87 -0.44 4.89 TP e. 114.559 24.298 139.45 78 11 461.82 23.57 -0.34 4.89 16-0 128.773 23.071 139.55 67 36 472.40 63.45 -0.13 4.89 16-0 109.421 58.662 139.76 80 14 459.77 50.03 0.04 4.89 L 125.113 49.305 139.93 113 32 426.47 31.54 0.05 4.89 T 146.193 28.917 139.94 106 6 433.90 8.54 -0.39 4.89 T 135.968 8.205 139.50 269 43 270.28 27.39 -0.62 4.89 UTIL 133.735 -27.390 139.27 149 7 390.88 31.81 -0.34 4.89 C 160.900 16.328 139.55 127 33 412.45 63.74 0.69 4.89 C 172.447 50.534 140.58 134 51 405.15 36.56 0.16 4.89 16-WP 159.384 25.919 140.05 149 3 390.95 45.84 -0.27 4.89 16-WP 172.913 23.575 139.62 152 59 387.02 8.68 -0.4 4.89 12-0 141.333 . 3.943 139.49 letup#3 Gun @ SPK-3 hi= 5.060 0 on SPK-2 El SPK-3 139.590 Deg Min Sec =>HMS Dist +- Hp Descr X Y Z 0 0 0 950.83 93.07 -0.14 5 SPK-2 133.600 0.000 139.51 345 42 605.13 16.30 0.86 4.67 CTK-0.6 185.534 57.363 140.84 2 38 948.19 31.950 -0.42 3.5 CSTP 171.092 48.335 140.73 282 57 667.88 18.600 -2.12 3.5 EOF 203.810 57.469 139.03 . 95 41 855.14 51.390 -1.18 3.5 CSTP-T 155.962 108.398 139.97 118 52 831.96 48.870 -2.09 3.5 TOW 174.116 117.475 139.06 106 13 844.61 38.780 -4.68 3.5 CSTP-DW 170.364 104.068 136.47 155 36 795.23 29.630 -4.72 5.12 DW 199.946 100.801 134.81 117 4 833.76 93.830 -2.31 3.5 DW 154.587 158.028 138.84 115 31 835.31 83.690 -1.74 3.5 L 156.613 147.808 139.41 133 11 817.64 56.870 -3.91 5 DW-WL 184.827 128.515 135.74 170 15 780.58 46.310 -5.34 4.67 PCSDW 215.141 112.487 134.64 210 39 740.18 16.710 -3.60 3.5 15-0 208.075 77.914 137.55 215 35 735.24 28.680 -4.99 3.5 15-0 220.062 79.691 136.16 142 2 808.79 62.930 -4.03 4.67. DW . 193.717 135.067 135.95 125 55 824.91 89.820 -0.94 5 DW 169.281 158.947 138.71 126 28 824.36 41.470 -6.18 3.5 DW 182.106 112.325 134.97 179 55 770.91 59.980 -6.67 3.5 L 230.211 118.704 134.48 159 27 791.38 68.130 -1.35 7.25 L 214.148 136.713 136.05 172 26 778.39 67.790 -3.46 6.75 15-0 227.919 129.885 134.44 158 46 792.06 94.860 -0.47 7 L 221.611 162.308 137.18 204 34 746.26 51.880 -8.28 4.67 L 238.917 95.104 131.7 131 8 819.69 8.340 -2.37 7.5 RW-1/2 190.986 80.372 134.78 193 45 757.08 69.890 -7.76 5.35 18-0 248.151 114.285 131.54 88 21 25 862.47 9.750 -2.27 8.25 HC-12 184.658 78.090 134.13 87 14 25 863.59 33.880 -2.20 8.25 HC-13 165.125 92.261 134.2 30 34 920.26 18.100 2.43 4.67 TOF 175.410 65.883 142.41 1 1. . Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection rad One winter Street' Septic Boston Ma. 02108 John Septi D.L.Y. Title V c Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CEiLLUCCI t f r Lt.Governor ��►� � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART A CERTIFICATION Property Address: 57 Crocker Rd.W.Barnstable Address of Owner: 0 T ?,7 Date of Inspection: 4114198 (If different) ��NoF 19 Name of Inspector: John Gracl Page Frenzof am a DEP approved system inspector pursuant to Section 15.340 of Title%(3 0 CMR 15.000) y�(Tti F jTgB� 98 Company Name,Address and Telephone Number: 8 b CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection la based on criteria defined In Title V Conditional) Passes code 310CMR16.303.My findings are of how the system is y performing at the time of the inspection.My inspection does _ Needs Fur her Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity ofthe Fails septic system and any of its components useful life. 1 Inspector's Signature: Date: 4114198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Conpllance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, Is cracked,structurally unsound, shows substantial infiltration or exhItration, or lank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 0407197) One Winter Street . Boston,Massachusetts 02108 • FAX(617)556-1049 is Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Crocker Rd.W.Barnstable Owner: Page Frenzo Date of Inspection:4114199 _ Sewacte backup or.breakout.or. hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed i 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to on overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Crocker Rd.W.Barnstable Owner: Page Frenzo Date of Inspection:4/14199 D] SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)97i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 57 Crocker Rd.W.Barnstable Owner: Page Frenzo Date of Inspection:4114199 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. -x_ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is — — unacceptable)[15.302(3)(b)] (revised WNW) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 57 Crocker Rd.W.Barnstable Owner: Page Frenzo Date of Inspection:arlafs8 FLOW CONDITIONS RESIDENTIAL: Design flow: = g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(Iast two(2)year usage(gpd): nfa Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: n/a Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nra Last date of occupancy: nra OTHER:(Describe) nra Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection:(yes or no)No If yes,volume pumped:0 gallons Reason for pumping: nla TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(if known)and source Information: 1970 wfth new plt Installed In 1993 Sewage odors detected when arriving at the site:(yes or no) No I (revlaed 04117)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Crocker Rd.W.Barnstable Owner: Page Frenzo Date of Inspection:4114199 SEPTIC TANK: x (locate on site plan) Depth below grade: t' Material of construction:x concreate metal FRP Polyethylene—other(explain) If tank is metal, list age we . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Lee^H5'7^w4'1o" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: ze" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:5" Distance form bottom of scum to bottom of outlet tee or baffle: 15" How dimensions were determined: Measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound.Recommend pumping system every two years. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_meta►_FRP_Polyethylene_other(explain) Dimensions: n1a Scum thickness:nfa Distance from top of scum to top of outlet tee or baffle:nfa Distance from bottom of scum to bottom of outlet tee or baffle: rya Date of last pumpingiil, Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rYa BUILDING SEWER: (Locate on site plan) Depth below grade: ve-, Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line?ems Diameter: nla Qmments:(conditions of joints,venting,evidence of leakage, etc.) (revlsed 0027197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add re s s: 57 Crocker Rd.W.Barnstable Owner: Page Frenzo Date of Inspectlon:4rta198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rya Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rUa Capacity: rya gallons Design flow: rda -gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: rda Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_rea Comments: (note condition of pump chamber,.condition of pumps and appurtenances, etc.) rda (rerleed 04r17197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Crocker Rd.W.Barnstable Owner: Page Frenzo Date of Inspection:4114198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rya Type: leaching pits,number: 2.1000 gallon leach pn leaching chambers,number:na leaching galleries,number: rda leaching trenches,number,length: Na leaching fields,number, dimensions:rda overflow cesspool,number:nra Alternate system: nh Name of Technology:_nia Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) Leach pits and all components or*structurally sound and functioning property.One pit had was full and the new pft had V in tt CESSPOOLS: (locate on site plan) Number and configuration: rva Depth-top of liquid to inlet invert: nla Depth of solids layer: rda Depth of scum layer: rda Dimensions of cesspool: nla Materials of construction: Na Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rda PRIVY: (locate on site plan) Materials of construction: We Dimensions: rda Depth of solids: rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n!a (reyleed 04J2V97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 57 Crocker Rd.W.Bamstabie Page Frenzo 4114198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) I I �C' E P 405 10 .61 �5 Ab 3L �7� C o Page ! of a0 (revised 04RTl97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION(continued) 57 Crocker Rd.W.Barnstable Page Frenzo 4114199 ` Depth of groundwater 12. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check.pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (revlsed04)2719>7 Page 10 of 10 TOWN OF BARNSTABLE PPP :.00AiION E2 L"r ocr—Ec- SEWAGE # 93-19,4_ VILLAGE LLB„ ASSESSOR'S MAP & LOT /0�—6LQ INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACIfY_NA LEACHING FACILITY:(type) vv— (size) NO. OF BEDROOMS PRIVATE WEL OR PUBLIC WATER BUILDER O OWNER Locx S DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: !FIyI 413 VARIANCE GRANTED: Yes No s I ' r �' V THE COMMONWEALTH OF MASSACHUSETTS ----- APPROVED BOARD OF HEALT Bornstable Conservation Dcpor TOWN OF BA R N STA B E 0 0 ® L/0 Diripinittl Wnr1w C omitrnstinn "permit Application is hereby made for a Permit to Construct ( ) or Repair (�d an Individual Sewage Disposal System at: Location- Address or Lot No. 15..........--•- � Z ----•--•-•••-•••••••-- �•-� �1 1, yOwner f Address A -------�C)ri��\`? s 1: c.:_. Cyr..... S` ` e`FN Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building _------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- -- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_...................sq. ft. 3 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........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ ............................................................................. 0 Description of Soil....? ---•--S......................... P .................... ... .....----------------- .......................------------------------------------------- ..._...---------------------------------------------------------------------- .. ------ ••---•--------------- W .......---•-----------------------------•-------•••----------•------------------------.............------.....-•--------..........._......--•---•---•---............................................... UNature of Repairs or Alterations S`Annswer whenae pplicabl -._.' 9�---.--.-- ----- Z?._......� 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. Signed ..... ----------- ------- ----- X{/..g. ........._. /Da[e ApplicationApproved By .......... ._ ............................................................................. .... . e-.� ...... Application Disapproved for the ollowing reasons: .........._...........................................................:................ ..... ............................ .................... ................. ........... ..... .... .............. ..... ......... ........... .-------- -------.......................................... ._................. ---------_-------------------------- Da PermitNo- ------------f�--�.--.....�...�.�---- ----------- Issued ....... ----......---.....................................f....... Dale .,...J1-y"`»-. 4�..� ....-r-'�.'.+r. ..-r_+!,.. .i' -� �'� - _.-••-. .- '':t r � :`1:.�. ^1 d•\r...��✓.. .-..�7 1..'4.-i..1 .1.�.,;_ . Flcs.... ......>........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT�H�'� TOWN OF BARNSTABL' E �M k U- 0 rtt#iuu furiuuul 3( urlt Cnu�t #rnr#iunCrruti# Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal- System at: :......................... Location-Address or Lot No. Owner Address =--•'••---- �� " ......... -•-3- 5!S,� a J Installer Address UType of Building s Size Lot............................Sq. feet ..� Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures .----••-•----------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity........__._gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.._....____..__._. . Total Length Total leaching area.._.._..............s . ft. P g g q I 3 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........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................._... •--•••---•••-----------------•--•--•-•-•••--•--•-••-••-•-...-----••.......-•----••----...----•-----.......--••--....••----..........................---....-- O Description of Soil--..O..-.\......_S Z................1:5--`' ...--••--......-•� _S>...-•--•-S N x V --------------••-•-•--•--••----••--------...................._................---..............---...........-----••---•------••......--••--................_._------._.....----- W ••--•------------•----------------•---_......................._................------------...---------------................---......------'-----..................--••--•--...-•----•-••--••-•------ Z. Nature of Repairs or Alterations—Answer when applicable.._..'?'�SZ�_........ ►`� ( ood_ 0�n t.,�Vjj_... - .... `...��" .7------------z\---------S--}�eJ-L--------- -� 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. Signed ..... ch-' 'k- -?`' ".............................. S .`/.....°i. .......... y Application Approved BY - - .-;- ✓ Da-Dace 7�...... Application Disapproved for the following reasons: --------------------------------------------------------------------------------- - --- -------------------- ------------------- ............ .......................................... ................................................................................ ............' .... ... ------------------'------ ..................... -' ......---- Permit No. ........... / 1 ................... Issued ......................................................... te...... Dare ,..r.---=.mo o.,—— ----._.—�--��a.., ---'-- m— ———— --.c.s� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BAR��TTNSTABLE �Ertifirate of Complianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ((b ) by ....... �_.X,_F4............. 'a.✓ .._........................I........................................ - ..--... -' ....... ' ..... .......................... .. Insrallc•r at .......5..7............� OCL-: ............. ..... ........ ZN%� - - has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......._............._....._..._....--...... dated ............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. �-..'.... ..'.. 7............ .___ ---- -----------..---- Inspector --_..... -' . .... ...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q q TOWN OF BARNSTABLE No.... l...j..".�.J � FEE.....3a... -'-== Ropouttt Workii Tuni#ru#iun rruti# Permissionis hereby granted---•- -------------------------------------------------------------------------------------------------------•-----------••-----•------.----- to Construct ( ) or Repair (?"-) an Individual Sewage Disposal System _ atNo...�7 .l!d(X' _ ........... - -•-••••.......--•.------�--7 .......................................... Street Cj as shown on the application for Disposal Works Construction Permit No.-P, Dated............................ %4t. - _ Board of Health DATE................3� " ...................................... FORM 38808 HOBBS&WARREN.INC..PUBLISHERS I LOCQ,TI N ' SEWO,C EE PERMIT MO. -- - - - vILLp�,E IWSTQLLER 5 IJ&M 4,- ADDRESS BUILDERS I &MF- �. ADDRESS DIQTE PER"lT ISSUED '- =/-3= t D ATE COMPLI &MCE ISSUED : G=9e� ' V r 0 LL No.........`6.a.....-- Flca....1....�1....:.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TAN- ..... -------OF..... ..STATE.............. Appliratioo -for Uiiipoottl Worbi Tonstrurtioo Vrrulit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: _Crocker Road-"TRAILVIEW"-_West_1.3a S bl Lot #29 . •---•---••-•--••-•--•-•.............•---•---•••-------••-•-•......•....---- Location-Address Z' or Lot No. SEA=T.AKF gQN9R8MM..................................... ......•- Box:264-•--Rt- �._.�A-.__S dwich,--Mass_------..-•---- Owner � Address Norman Ayotte .....175..Main.Et.--Sandwichr--Mass........................... Installer Address 35,200 Type of Building Size Lot............................Sq_. feet Dwelling—No. of Bedrooms-----.th.. ---••----------------•- V11 VV)W `)X9( aOther—Type of Buildin4.-StOXY--_�T1Ch No. of persolts____________________________ Showers dOther fixtures -----------•-•---••--•------------------------------------------------------------ Design Flow..... _ gallons per person per day. Total dailyflow........�..-----••----------•-- ------- gallons. Septic Tank Liquid capacity� ..gallons Length................ Width................ Diameter................ Depth_..--.__.-.---. W Disposal Trench—No. .................... �1�idtli___.________ _._.. tal�Length--_-___----_........ Total leaching area....................sq. ft. x Seepage Pit No..... .............. Diameter-,/ -_---: epth below inl t.-. --__ _-.... T 1 leaching area.-----._----.=__-_sq: ft. Z Other Distribution box ( ) Dosing tank ( ) 4 � � �' ��" 7 76 Percolation Test Results Performed by._--------Alan Jones . -----•---••--•-...-•---•......-•••-••-••-••••• Date....12-18-25----------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground-water...--.----_----.--.--.-. f� Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water---------_---_--_---..__ 9 ------------------------------------------------------------------- ......................................................................................... 0 Description of S �l_.---.._See__4t dj --- U 7 ..._. -. _ q-f..... .y.... ...........:.......... .----- � n`y,�, ............ ..........lam-__.___ ..__. _. .. ... ______""""'. .._ .. _ _ _........__ _ ............ . _ __ -----------•------ W V Nature of Repairs or Alterations—Answer when applicable._...................................•--_.-__-__._--____--.-_.__-.-_------.-..-._--.----_---.... ----------- -----------•--•-------•--------------••------------•-------------------_.-----•--•----•-•----•----------•----------------_--------•-------------------------------------•----•-------------. Agreement: The undersigned agrees to install the aforedesc ' ed Individual Sewage Disposal System in accordance with _the provisions of Article XI of the State Sanitary C e T e u ersigne urther agrees not to place the system in operation until a Certificate of Compliance ha�ee iss ed th oard f ealth. Sig -••-•-- ------------------------------------- --2-13-76.--•-•--•-••- Date Application Approved BY-------- -- - ----�-- ------ -- =-------------------•---- 'Z_-2. '.7 h._... Date Application Disapproved for the following reasons:.......................---------........-........................................................................ .....................................--------------------------------------•---•-•----•-•-•---•-•-------...-----•------...........................-•-----------•---..._............-----•---•.......... Date PermitNo......................................................... Issued.-%..._................................................ Date 76 �: 7 No......................... FE/o................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .....TW... .........OF.......BA�ISTABLE............................... ...................... Appliratinn -fur Rupusal Works Tonstrnrtiun Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _Crocker Road-"TRAILVIEW"- West Barnstable Lot__#29_________________•_____-_-__-_______•__•_____•---•------•----._.......------ Location-Address or Lot No. ................E AI CO ORATION------•-•-•------------------------------------- .....BOX-.264--'-l.�tat...6A....7..SCMaAChf--Mass......... Owner Address W Norman Ayotte___..__... 176 Main St., Sandwich, _Mass.-_---------------------- --------•-•-...... ---•--------•---•--------------•---------••-----..---- Installer Address 35,200 d Type of Building Size Lot............................Sq. feet iDwelling—No. of Bedrooms--------three----------------•_...ly)(Mawmim GL, Other—Type of Building 1..StolY..B�o. of persons---------------------------- Showers a' Other fixtures ---------------------- --- - -------------------------------- W Design Flow.-..---••• ....................-.}gallons per person per day. Total daily flow........�3....-....-.......................gallons. WSeptic ".Conk Liquid capacity�f'_'Ygallons Length.--------------- Width-----_-_--.-.- Diameter_---- .......... Depth-.-..-._..----- x Disposal Trench—No..................... Width...-------- � tal`L ength-..-.-.-....._._.-.. Total leaching area........_.--..._._-sq. ft. Seepage Pit No-----/------------ Diameter. ...... Depth below Ie J�1, ._-._.. Vplaing ----------sq. ft. z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by Alan Jones -- Date-..-.12-18-75 a - - a Test Pit No. 1................minutes per inch Depth of "Pest Pit --..-.---......... Depth to ground water . --- ----- . (� Test Pit No. 2................minutes per inch Depth of Test Pit..........---------. Depth to ground water..............._-_----. Ix ------------•------ ............................. 1 -----------------•-......................................................... W Qw`sSeO Description of o .-�.----- rt: -------------------- V r ....................................................ik �---------- --_------------ ------------------------- -------------- ----------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable.-........................................._..-.--.._---.-..._.---.------------------_------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of e State Sanitary Code 1 The undersigned further agrees not to place the system in operation until a Certificat omp 'a h�i eenrissued by the board of health. u! -------------- . Date ApplicationApproved By-------------------------------------------------------------------------------------------------- ---------------------------------------- Date Application Disapproved for the following reasons:----••----------------•-•--....-..---•------•--•-•-•---••-----------------.-.-.-...-----------•----------------- ...........................................•-.--.------------.........----------•---•--------------------...........---------------•-------------•-•----.........----------------..........-----------•. Date PermitNo......................................................... Issued....................................................... Date THE COMMONX4G*,r--H-E TH OF MASSACHUSETTS BOAALTH ...................................OF.......................................................................... . of Tomplinnrr 7 9C I cS I %�� F hat Ind C evlr�ispos ;iSys construct ,or Repaired ( ) oo� by....... ' _._----- .._•---------•-•------------- •nstalle� -------------------------- at......................................................................... ��` - - -------------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated----- ........-__----..-_--------.._...------.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............................................................-----•----------- Inspector.................................................................................... THE COMMO EALTH OF SS CHUSETTS A .........................................OF..............................................................................----• /U No......................... FEE........................ � v '� utt� ! nfinat Prrntit > "e rs on > e�ly ed -- ---------------- te jj `C to Construct ( ) or Repair ( ) an Indivi ual Sewage is Peal System s �7 as shown on the application for Disposal Works Cons c Li ------------------------------------------ ar oar$ d of HeaIt — DATE 3..--- �.... ........... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS J .. �,_.. ..mow... w.ro.a.wm-. �._....�.A1......-_........ ......_..�...�..._.......-�.__.-.........�........._, »�;.. ._,... .y...»... .. ..xi... .re.�,..-_..,MwPa--..-_.._ I � e t /ji f Y 1 IV I 1 I el li � I f 1 1 f!n•,i/.� I,h/ fy•rr r'; ��r f'�.rt i It,-A r�� r �Y: . !,. Y .. . �!' • .} 1' !i [� � .1< �N"y".�t�l.�.. /'��{j' t I..�. 1w �11, _.._ _+V�/��+�.C . tS •�� / < � ,�'w Vet lr` lt�r � '^/I�♦ ��/.s�` } 1♦ \In�n9 l k 9 't 11 � 8►�► trr�� ...:�.% {/ F''' ��... t' r�r r'�`�'� . _ VY/ L F�F �� MAR 0 3 � 2005 ri�," 4 S t HISTORIC aka OF�, r,�9 T y _ 0 SIN 9� F-v • r s ' } ...r q f f - 70 L I u 11\1 t..,. 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