HomeMy WebLinkAbout0139 CROCKER ROAD - Health 139 Crocker:
W. Barnstable F/R
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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �d LEACHING FACILITY: (type) _ I S (size) 6
NO. OF BEDROOMS �^
BUILDER OR OWNER ICE C4 W,4,n
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist t"
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on site or within 200 feet of leaching facility) 5o Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
Feet
within 300 feet of leac�ng facility) 1
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
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,
use only the tab 1. Inspector: �pC
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S.M.Jones Title V Septic Inspection
r� Company Name
74 Beldan Ln.
I Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com S14522
Telephone 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. 1 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
6/17/2013
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner'
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
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:
The dwelling located at 139 Crocker rd West Barnstable is served by a Title V septic system
consisting of a 1000 gallon septic tank, distribution box and 3x500 gallon leaching chambers. The
system was found to be in proper working condition at the time of inspection.
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
r,.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will bass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.'' 139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. Cityrrown 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 Y2 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
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary'to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered'yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
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): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 459.9 gpd
provided
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
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
'Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cost.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
s.a.s installed 9/27/02 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
6"
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 139 Crocker Road
Property Address
Susan Cox
Owner Owners Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. Citylrown 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
3"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers, took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Inlet
cover is located under brick patio, outlet is on a riser.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. Citylrown State Zip Code Date of Inspection
Do System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was in good condition, no rot, water level was even with outlet invert.
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
new s.a.s. was found to be dry with no sign of past hydraulic overloading. Old leach pits are still
connected to system, these were not located for this inspection.
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,•''y 139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. City(rown 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
a
LL'
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. Cityrrown 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
(L6,19_ OF J-tolJ E
4
o
f Alu
,q-I �3ist° � � � 3 � z
29 '
aBaX
SAS
A ,3 r
3 . 7/
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 7/12/2002
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing design plan dated 7/12/2002. Plan indicates
that no groundwater was encountered at 144"and system is designed to have 5'+ seperation
between bottom of s.a.s. and adjusted high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
139 Crocker Road
Property Address
Susan Cox
Owner Owner's Name
information is required for every West Barnstable Ma 02668 6/17/2013
page. Citylfown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
N. --- 033 Fee---- J--- --
BOARD OF HEALTH
TOWN OF BARNSTABLE ���
ApplicationArVell Confitructionpermit
;� �Wel
.�- �.
Application is hereby made for a permit to onstruct ( ), Alter ( ), or Repair ( )an individua :
P
-�--g------0&_�U -- ---- --- - 1 p=p ---------- ----
-------------- -
Location — Address Assessors Map and Parcel
---------=� 11/ --a res Driller _Address
Type of Building
Dwelling — 1_ rf --------------------------------
Other - Type of Building --- No. of Persons-------------------------
Type —__—__________
ofWell—----—------------ --- ----—-- - —- - apacity---------------------------------------- -----
/1 "� -- - —----
Purpose of Well------- ---------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate .of Compliance has has been issued by the Board of Health.
Signed - -"' - ------------
— _ cvo�
date r
Application Approved By -P;_ ---� -----_--------- •__-----
date
Application Disapproved for the following reasons:-----------------------------------_----------------_-_--__-_-__________—__________
------------------------- - --------------------------------------------------------------------------------
date
Permit No. -_ oV�— _ ------------------ Issued--74-44 F--------------------------- --------------------
date
- - - -- ----- ---- ----------------------------- --
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individu Well Construe�Ee`d ( / rE '(� 1��'ired
by-- - . - -------------� -- y`-' — --- -
Installer
at- - --�1���� ------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. 1,,--2449-=a1Dated--1-4f4------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE --- -- - -- -- —---------- --- — -- Inspector------------------------------------------------------------------------
'_� 3
NO.-�- -vU _ Q S Fee------I-z;A----------
BOARD OF HEALTH
TOWN OF BARNSTABLE
ZIPPiicationArVell congtructionigermit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
--------------- _9__------- a o -1t ✓_ — --- - 1 Q�o
----- -- -------
Location — Address Assessors Map and Parcel
Owner Address
--- -_�___ �
Installer Driller Address
Type of Building
Dwelling —'o�- r� - - ----------
Other - Type of Building------------------ ---- No. of Persons--------------------------_--_—__________
Type of Well- -- -- ---- - ------=— Capacity - --—
Purpose of Well------• -n'-j'`- -- ---- ---
AgreeMentl
_ The undersigned agrees to install the aforedescribed individual well in accordance w th thCp ovisions�&'-"The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
,QQ date
Application Approved By --- ----If`" ___—_-___-______-- '-.2 - 0�--
--- ---
`1:,1 , r'4 + a F^ {. Aye' r date
Application Disapproved for the following reasons------------------ -----------------------------------------_____________________
------------------------------------ ---------------------------------------------------------------------------------
date
PermitNo. --------- ---------- Issued-----r--L44?----------------------------------------"=-----
date
---------------------------------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
€ _ (Certificate ®f (Comprianre-
THIS IS TO CERTIFY, That the Individual Well Construc�fe`d /�( iZepafed r/-'"TrZ-L'
by------ A -- � �L: I, J�0![1 L fir -rj- =-----------------
,(,� Installer --------------
--------
at- -�-- d 1 = - ------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
-
Regulation as described in the application for Well Construction Permit No. ! C _—( l^Dated----G�.2-b -------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------------------------------------------------=--- - -- Inspector-----------------------------------------------------------------------------
-------------------------------------------------------------------�
BOARD OF HEALTH
TOWN OF BARNSTABLE
Yell (Congtruction-permit
No. ;a�
Fee----- ------
49 r��e��.
Permission is hereby granted--r-- --------------------------------------------------------------------
-- --
to Construct ( ), Alter ( ), or Repair ( ) an Individual Well at:
No. - - --- roj-ln!_- �2'—-------_-------—------------------------------------------------------------------------------------
Street
as shown on the application for a Well Construction Permit /
No.------- -2 ay . (i - ---- -- - - Dated-- L---
- - -----------------------------------------------------------
07 Board of Health
DATE--------T----�-k----------------------- I�
';Lt Jo>�yQrL e.
CERTIFICATE OF ANALYSISPage. 1
` Barnstable County Health Laboratory
Report. Dated: 8/10/2005
Revol-t Prepared For:
Order No.: G0532325
Susan Cox
139 Crocker Road
W Barnstable, MA 02668
Laboratory ID#: 0532325-01 Description: Water-Drinking Water
Sample#: 32325 Sampling Location: 139 Crocker Rd.West Barnstable,MA Collected: 8/8/2005
Collected by: S.Cox Received: 8/8/2005
Routine
ITEM RESULT UNITS RL MCL Method# Tested
LAB: Inorganics
Nitrate as Nitrogen 2.2 ,ng/L 0.10 10 EPA 300.0 8/9/2005
LAB: Metals
Copper 0.16 mg/L 0.10 1.3 SM3111B 8/9/2005
11-on BRL mg/L 0.10 0.3 SM3111B 8/9/2005
Sodium 17 mg/L 1.0 20 SM 31 11B 8/9/2005
LAB: Microbiology
Total Coliform Absent P/A 0 0 309 8/8/2005
LAB: Physical Chemistry
Conductance 170 umohs/cm 1.0 EPA 120.1 8/9/2005
pH 6.9 pH-units 0 EPA 150.1 8/9/2005
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved B • *
(L irector)
.vt,.
RL =Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, 1VlA 02630 Ph: 508-375-6605
TOWN OF BARNSTABLE T�-
�. t�� �.��c�cer . SEWAGE # Z (:U 2—3
LOCATION. 0 I
GE ASSESSOR'S JMAP &LOT �'
... VII,LA � ! j
INSTALLER'S NAME&PHON71
E NO..
SEPTIC TANK CAPACITY
c�g l l3
LEACHING FACILITY;)3 WtcI �Ic size) 33 Z. K
NO. OF BEDROOMS__`
BUILDER OR OWNER f V UYL
PERMIT DATE: z COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Feet
Private-Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility (If any wetlands exist Feet
within 300 feet of lea 'ng f cili
Furnished by
r 1
' `Z = 95'
eL
,7(r
Dry wept
i
_ 'TOWN OF 13ARNST'ABL>✓ �-
E_
LOC'ATiON be� SEWAGE # Z GU 2—301
7
VILLAGE MI ``� W4 It ASSESSOR'S fMAP &LOT
INSTALLER'S NAME&PHONE NO t tnl��' TrJC S $I SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)3 r,,5,V U.J w'v-0 4'&tw ize) 33 VZ X
NO.OF BEDROOMS
BUILDER OR OWNER f i 000'cV VLF
PERMITDATE: Z. COMPLIANCE .DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of lea 'ng f cili Feet
Furnished by
40 a
icy we�
11[0.
oC W2 _ f � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for 33igo5al *pftem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( ✓Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. 1 Owner's Name,Address and Tel.No. C JpI l „
Assessor's Map/Parcel i 13 ® n , I
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date -7 A' �� Number of sheets Revision Date &4 4
Title
Size of Septic Tank Type of S.A.S. i` ' 331 S�
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Hearth.
Signed ') y Date 7 a
Application Approved by Date 7 b
Application Disapproved for the following reasons
Permit No. 00 2-3a Date Issued
Fee
i, ..` :
1 THE COMMONWEALTH.t A'S' SACHUSETTS Entered m computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF.BARNSTABLE- MASSACHUSETTS
J rication for igooarpgtein �Con5tructionerntit
t. ,
Application fora Permit to c�nstruct( )Repair(' )Upgrade(V)Abandon(` ) El Complete System ❑Individual Components
Location Address or Lot No. � 3� � Owner's Name,Address and Tel.No.
1r1-_ Hrn '-f' �o�'Wr . 50$_
Assessor's Map/Parcel , '1 h 13
17:0 . 73 — 5 ? 2
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
a -7-7,S
Type of Building:
Dwelling No.of Bedrooms"' _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow i D gallons per day. Calculated daily flow 4 gallons.
Plan Date ,m Id1a Number of sheets 1 Revision Date
Title .
Size of Septic Tank
q IDOU Type of S.A.S. 13'9 33.'s�-A a
Description of Soil .J. -20,
Nature of Repairs or Alterations(Answer when applicable)_ il71hNd -
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health
Signed Date 7 ;�Q O ea+.
Application Approved by e► J Date 0
Application Disapproved for the following reasons
Permit No. D 02- 3 r7 Date Issued . 1
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERT�Y,t at the On-site Sewag Disposal System Constructed( )Repaired( )Upgraded(�)
Abandoned( )b
at Is � o has been constructed in ccordance
with the provis" s f Title 5 and the for Dis osal System Construction Permit No. �Uo�- / dated '?
Installer Designer ! x tQJ�orc,. ✓
The issua ce of t °s pe it all not be construed as a guarantee that the syst will function as de " ed
Date - V3 Inspector
lu r-41
--------------------------------------
No. V 2— 31 / Fee d
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS
Bigoal *p5tem Construction Permit
Permission is hereby granted to Construct( )Re/� " )Upgrade(i/ )Abandon( )
System located at�)�� eA� !b
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. p
Dater 37 Approved by �,vC �•
[ �l
r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
o6 EC!'OIV
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A RECEIVED
CERTIFICATION
MAY 0 3 2002
Property Address: 139 Crocker Road
West Barnstable, MA 02668 TOWN OF BARNSTABLE
Owner's Name: Kathy Cowan HEALTH DEPT.
Owner's Address: Same Q
Date of Inspection: March 14, 2002
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map: 110
. Osterville,MA 02655-0049 Parcel: 013
Telephone Number: (508) 862-9400
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 system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
✓ Fails
Inspector's Signature: Date: April 1, 2002
The system inspector shall submit�copyy this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing,this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 139 Crocker Road
West Barnstable, MA
Owner: Kathy Cowan
Date of Inspection: March 14, 2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
I
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 139 Crocker Road
West Barnstable, AM
Owner,, Kathy Cowan
Date of Inspection: March 14, 2002
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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
.private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
;the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
f
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
i
Property Address: 139 Crocker Road
West Barnstable, MA
Owner: Kathy Cowan
Date of Inspection: March 14, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
Yes (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 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•
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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.
4
i
Page 5 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 139 Crocker Road
West Barnstable, MA
Owner: Kathy Cowan
Date of Inspection: March 14, 2002
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.ank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of canstruction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ _ Was the facility awner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 139 Crocker Road
West Barnstable, MA
Owner: Kathy Cowan
Date of Inspection: March 14, 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Private well
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:-
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped approximately 4 years ago-per owner
Was system pumped as part of the inspection(yes or no): 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 own&)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
New pit installed in 1987-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Crocker Road !
West Barnstable, MA
Owner: Kathy Cowan
Date of Inspection: March 14, 2002
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 6"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
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 tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139,Crocker Road
West Barnstable, MA
Owner: Kathy Cowan
Date of Inspection: March 14, 2002
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (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: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Crocker Road
West Barnstable, MA
Owner: Kathy Cowan
Date of Inspection: March 14, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,:number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Typetname of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
The newer pit was an overflow of an older original pit. The newer pit was full. Liquid was up to the top and into the riser. The
bottom to grade was approximately 10'. The cover was approximately T below grade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
J
Page 10 of 11
OFFICIAL.INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Crocker Road
West Barnstable, MA
Owner: Kathy Cowan
Date of Inspection: March 14, 2002
Map: 110
Lot: 013
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
13A(-k
A
13
Q3 n2r a YJ
a3✓- 3�
11CwV priclinA
10
Page l l of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Crocker Road
West Barnstable, MA
Owner: Kathy Cowan
Date of Inspection: March 14, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach pit to grade was approximately 10'. Using the Barnstable topographic map and the Cape Cod
Commission water contours map, the maps were showing approximately 50'+/-to ground water.
This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,
either expressed, written or implied, relating to the system, the inspection and/or this report.
11
-_, c TOWN
�OF BA�,R"-N-S-TABLE Q
LOCATION 7 %C�/t'�.�Q V/_SEWAGE # ® /4 1
VIL ASSESSOR'S MAP & LOT i I 0
INSTALLER'S NAME & PHONE NO. e c5' fI,--le 7 7 S 3 3 .35'
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)• C` Le LL(size) tR
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WAT
BUILDER OR OWNER: (,U
DATE PERMIT ISSUED: i
DATE .COMPLIANCE ISSUED: 1��'� '7
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEA T
r
........ ...........OF........ ' �� .............................•.•-
Applira#ion for Bi_gpmal Works Tumitrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location.Address .......Lot No.
... Ow
Address
...............................
Installer Address
Type of Buildin,g�. Size Lot............................Sq. feet
U Dwelling•K. of Bedrooms.. . ...................................Expansion Attic ( ) Garbage Grinder ( )
04'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Pa Other fixtures ------------------------•-•-• -- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity......._....gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—.\To. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.........................................
Test Pit No. 1................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........................
---•------•-----------------------------••-----------------•---•--••-----•-----•••••---•-----•--•--•.........................................................
0 Description of Soil........................................................................................................................................................................
x
----- --- ------
y }}
UNature of Repairs or Alterations—Answer when applicable________1�_ dl��""__ ,lk .l�s �___.__._._..pl..............
----------------------------------•-•• •-------...---------•---------------------------•---._............---...-•----•--•••••-••-----•--•---•-•----•---•=-•-----•••••••••------•-•••--•...--•-••......•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TT LE ;of the State Sanitary Code— The undersi ed further agrees of to place the system in
operation until a Certificate of Compliance has bee issuedebb�bo OAA
lth.
Signed_ .. . :.: . . •.._... =-
Date
Application Approved By............. ^^^l J ..................
Date
Application Disapproved for the following reasons---------------••-•---•-•---------•----------------------------------------------•----•---•••--•---------------
Date
Permit No....... _n.../-q..l
-•-------------------... Issued....... .....................
Date
No.--�-1.-..��L Fes$..� �,•���.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H, TH
ApplirFa#iun for Mipug al Worse Tonsirurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
/r � ,, ,� f
J/ v -
A ...........................................................................................
Location-Address or Lot No.
t__. ................. .....•. ..................................... ._.__.......__.._._.... ..
Address
Installer Address
d Type of Building Size Lot............................S q, feet
U Dwelling� o. of Bedrooms. ___Expansion Attic ( ) Garbage Grinder ( }
Other—Type of Building _________________ No. of ersons._..._____.________.___.____ Showers
a g ----------- p ( ) Cafeteria ( )
dOther 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.
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_______________________.
f.4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ix ---•----------••-••-••-•-------•---•---•---••.............................................•---------........................................................
0 Description of Soil........................................................................................................................................................................
x
W ..._....................... ..
U Nature of Repairs or Alterations—Answer when applicable...____.�_:_,�. J� F"_____________!
-•-----•----•-----------••--•-•-----•••-----------•--------•-•-•-••-•---•------•----•---•-•-----...-•-----------•-------------•----•-•--•----------------••-------•-•---...............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provprovisionsnl-^
of f•1T is i:.c:. ; of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beep issued by t 'boarJof health: r
/
Signed ``' .... ' '°j... f ..................... ...............
Date
Application Approved B
Date
Application Disapproved for the following reasons:-----•----------------=---------•----------------------•----•------•-----------••-------------------......------
----------------------------••----_...--..---------------------------•---------------------••----...._.....-----._..:._...----.................=.........................................................
Date
Permit No........ff�_=._.I.q•1--•---•----------------- Issued.._..--�-'--3.71E.2.2....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
�,.r BOARDFf-JHEAD �'"
/�
......mil/... . OF....
Tv r if iratr of f omplia"r
THIS TIFY, What e Individual Sewage Disposal System constructed ( ) or Repaired
has been installed in accordance with the provisions of T i T i E 5 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............. --7---------------------------------------- Inspector.........
- �.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
........... .- .HEALTH-
0 F..
................... .
No....Y.7•A �
FEE....
Biopullul IV"ikvx(gonutrt fait rruti#
Permission is hereby granted / ______' =� : _ '' ___.
f ,,r.................................................
to Construct s,}_nor Repair ( `>)4atj Individual Sewage Disposal System' ��
a
at No.......r_' __'=°`-�_ ..__-----r r.�5-- :_`L.=''�'....�'.t�w,.+�......_._..a..._............................J {
T re.--'•� -�---•___________________•_----------•___._..._._....-..__
Street as shown on the application for Disposal Works Construction.,Permit No._ /�I�r
Dated........ �Ik...A.7.........
Board of H
DATE........�-- ----------•----------------•-_-------•----
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS -
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PRO'I L-.E: TO SCALE TEST HOLE LOCH
2"LAYER OF 1-IV'PEASTONE
iZ= FIRST PIPE LENCITH OVER�/A""-I V7"DOUBLE
TOP FaJ VAT,;N 6,WERS To WITHIN To M SET LEVEL WASHED wore DATE: JUNE L 2002
TcN
�- o' Or FINISHED GRADE FOR MIN- 2 TESTY: M.O'L00&tiLN,GSE
rE� FINISH 6RADE PER(,RATE: <2 MN/N
A" PVC, 4" PVC, TOP 9 E- .5—/, a
cyc� .xr e3'O F OR6ANr. „5GF1 AO ,5'0. 3 ., (�" e�rRrr�er DRMdLs ,3 2
GZ.S �sr,�ueAsarru� DOTTOM ® EL yB,3 A=LOAMY
f GCMG cJ S G S,o �(, a iNa�mer r� �/•/7 DIST. Dlh( T 53.2 9„
i7670 6AU_llrl 5' SEPARATION (MINIMUM) Cw=LOAMY SAND
2.5Y6/6
5EFrI6. TMK
(EXISTING)
6" STONE DASe POrrOM Or TEST HOLE ® ELEV. A10
F hE SAND
25Y7/A
DE5 ION DATA
k2.0
DAI LY FLOW: (4)f5EDROOMS x 1 b GPD=440 OPD 144"
SEPT r,TANK: 440 6PD x2007.=550 GPD NO WATER EN(OUNTEREP
USE: EX67N6 000 GALLON PRECAST SEP1"6 TANK
LEACHNG PAGLr Y:
USE: (3)500 GAL.PRECAST DRYWELLS LINED WFH A'OF
DOUBLE WASHED STONE ON SIDES&ENDS
CAPACITY:
SIDEWALL: 53 x 2 x 0.74 = 137.G
f5OT70M: 13' x 33.5 x 0.74 = 322.3
TOTAL: A55.9 GPD
70
/ \. GENERAL NOTES
C�l _ ' M.4) ' ( CONTRACTOR TO f5E RESPON615LE FOR THE LOCATONOF ALL UTLrFE5,
Af5OVE AND UNDERGROUND,PR OR TO ANY EXCAVAT ON OR GONSTRUGT ON.
SEPTL' SYSTEM TO 15E NSTALLED N GOMPLIANGE WITh 3V CMR 6r00:TFLE V
TT
I
vr_llSi=1/FOR i'KvFcK I YLYVC PET CKIVIiVA i
I` EX6TM7
WELL
J \ / 4. ALL POTUR15EP AREAS TO 15E LOAMED AND SEEDED
5. CONTRACTOR TO PROVDE 74 HOUR NOTCE FOR ANY REQURED NSPEGTkONS
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w/?-s� / LOCATION. 139 (ROCKER RD., WEST f5ARN T fLE, MA
PREPARED FOR: ED COUTURE
OF Mqs / / / SCALE: DRAWN PAY:
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�� JOD NUMBER: 12 9-I —
DATE: ter/ Z-bz SH
40 / OZ-078 DULY 12, ZOOZ SP
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Fss10 'At
WELLE G I ATE�3
1(o,45 FALMOUTH RP N SUITE 40 (ENTERVILLE) MA 024o32
TEL.: (508) 775-0735 � FAX: (505) 775--0154
PROFESSIONAL ENGINEERS & LAND SURVEYORS