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0140 CROCKER ROAD - Health (2)
140 CROCKER ROAD, W. BARNSTABLE A= 110 024 i TOWN OF BARNSTABLE LOCATION 1140s'roehcr RoL SEWAGE# 20 it, • /10 VILLAGE L). Barc%siaS)c ASSESSOR'S MAP&PARCEL I/p UZ q INSTALLER'S NAME&PHONE NO. J341$ CXCa►V0A'1 on 4471 06S3 SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) 300 2 a I y C (size) 13 X Z5,9 Z NO.OF BEDROOMS 3 OWNER Jc 'rcu QcwuSaflq PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facilitywetlands exist within (If any 300 feet of leaching facility) Feet FURNISHED BY A►- 19 '� f QZ ZG A3. 0 � 83 Aq- 41 0 ' n f t No. 7,, ,6— ` 10 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes IpYILat101Y for �I9 8AYp�tPU� C01�8tCUttiOYlCrU1It Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System �ndividual Components Location Address or Lot No. , 0 ner's Name,Address,and Tel.No. Assessor's Map/Parcel � r/� au 5Ct n Installer's Name,Address,and Tel.No. Des er's Name,Address,and Tel.No. �3f& Ex(_ctV0,Ji00 .S09 °477-06 ����,l5sbuafe-s 5o 00.q J Type of Building: Dwelling No.of Bedrooms \3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design�w provided gpd Plan Date J�I �O Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) to Cz N 2a 5 oo • �h be(� 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 th vironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f He h S' a Date CD Application Approved by Date Application Disapproved b Date for the following reasons Permit No. ZO/6 -- ]r 0 Date Issued �p / `� No. !/„ ✓I l7 — 110 Fee '` </0 computer: THE COMMONWEALTH OF MASSACHUSETTS Entered in com P Yes PUBLIC HEALTH DIVISION -TOWN'OF BARNSTABLE, MASSACHUSETTS Npfication for his osai 6,pstem Construction 3permit 4 Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System I Individual Components Location Address or Lot No. O LrUG ner's Name,Address,and Tel.No. Assessor's Map/Parcel vS�)9�e F F- _8 C a U 5a(1 5 U e -�3 7- 3 u Installer's Name,Address,and Tel.No. Des er's Name,Address,and Tel.No. Rf Q �y('0VC000 SZl2 77.06 ����1ss�ualPS 33 . 00JA Type of Building:Dwelling No.of Bedrooms \3 Lot Size sq.fr. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33gpd Design w provided _ pd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 U Q C Z 500 CAA• &h Cirn bN(5 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-9 vironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board ,f He h S' e <�'MJ' Date Application Approved by Date W/17 Application Disapproved b Date i for the following reasons Permit No. I rp - I t 0 Date Issued u ------ ---------•--- -- - ----------- - ------------------------ ------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance � THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired Upgraded P Y ( ) P ( ) ( ) Abandoned( )by ( a V o at I 4 a C�U�k{'.l �r.���V�� - (J((}� has been constructed in accordance with the proP0b,CE_T_ ions of Title 5 and the for Disposal System Construction Permit N T `D% ' 1 lU dated I Zo/(, Installer 1 1SQ Designer \ S n<jC1 i P C #bedrooms Approved design flow �j �(7 god The issuance of'his permit shall not be construed as a guarantee that the system will farietion,as designed. �� Date_ J �0 Inspector V E,W No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal bpstem Construction J)ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at 140 ,,('n - A Y-4 a cf_o and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with i Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permits Date t ( I j Approved by L:/ Town of Barnstable Regulatory Services • $ Richard V. Scali,.Interim Director BASTABL& H03 . AM A,� Public Health Division Thomas McKean,Director 206 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax- 508-790-6304 Installer & Designer Certification Form Date: Sewage Permit# -:Z 016 r HO Assessor's Map\Parcel Designer: & !�S c—4?ks Installer: �l� C � / / </' Address: Address: ./u, Ak On � 6'/� � g � AO!A®14. was issued a permit to install a (date) (installer) septic system at AA6 6A ekey Al'e-71 based on a design drawn by (address) 1 6elyk5. dated. (designer) V11"I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory: I certify that the system referenced above was constructed in co liance with the terms of the IAA approval etters (if applicable) �NORiygs AL y� o VON HONE (Installer's Si to e) v # s`���sz ati 9NlTAF�.P� esigner's Signature) (Affix DesignefMihffip Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTA.BLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverse so that we can return the card to you. v' ❑Addressee I ■ Attach this card to the back of the mailpiece, B eceived b (Printed Name) ate of Deli/very or on the front if space permits. ( � II,IS�Vt —1S�! 1. Article Addressed to:. _ D. Is delivery address different from item 1? ❑Yes Jeffrey R. Bea USa ng I If YES,enter delivery address below: 03-W 140 Crocker Road i I West Barnstable, MA 02668 I � I 3. Service Type ❑Priority Mail Express® II I'lII'I I'll l'I I I I I I I II II IIIII I'I II"II II I III 0 Adult Signature p Registered Mail I I ❑Adult Signature Restricted Delivery fJ Registered Mail Restricted y Q Certified Mail0 Delivery I` 9590 9403 0922 5223 8279 77 ❑Certified Mail Restricted,Delivery O Return Receipt for ❑Collect on Delivery Merchandise Collect on Delivery Restricted Delivery 0Signature ConfirmationTM I_2._Ar#cle Number(fransfeY from service label)- ❑Cod Mail,. nature confirmation I e i ,��• ❑Signature 7 015' 15.2 0 t 0 0 011 k t2 2.7'°3 t`-3 2 7 2` i•s�red Mail Restricted Delivery s 1 Restricted Delivery :r$500) 1 PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return.Receipt 1 USPS.TRACKING# yF�st-�Ias,�„�jail I . ._. + <.aa+�Y` { g Fas Paid iM G�yJ . .. ........ 9590 9403 0922 5223 8279 77 I United States 'Sender:Please print your name,address,and ZIP+4®in this box* Postal Service Town .f o Barnstable Public Health Division I ,+ 200 Main Street N ' Hyannis, MA 02601 All ill ijlll III)11111il fill Ol101111111111111111111iilill'ii 1, COMPLETE .N COMPLETE THIS SECTIONON DELIVERY ■ Complete items 1,2,and 3. A. Signature /� } ■ Print your name and address on the reverse Jam/ L9'rTKgent t so that we can return the card to you. X v' ❑Addressee ■ Attach this card to the back of the mailpiece, I3 eceived b (Punted Name) qqte of Delivery { or on the front if space permits. I ltSfA K _��Co�� 1. Article Addressed to:. D. Is delivery address diffemn from item 14 ❑Yes f Jeffrey R. Beausang If YES,enter delivery address below: M-W 140 Crocker Road West Barnstable, MA 02668 II I'lll'I I'II�'l l I I I I I II II III�I I II'I'III II I III 3. Service Type ❑Priority Mail Express® ❑Adult Signature ❑Registered MtiITM x ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted j ❑Certified Mail® Delivery +9590 9403 0922 5223 8279 77 ❑Certified Mail Restricted.Delivery ❑Return Receipt for ❑Collect on Delivery Merchandise 2.'Article Number,pransfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationTm i '4 'red Mail ;; �, - ; 0 Signature Confirmation 7 015;. 15 2 0%'0 0 01 i 2 2 7 3 ; 3 2 7 2 f tired Mail Restricted Delivery t i i t Restricted Delivery 'r$500) PS Form 3811,July 2015:PSN 7530-02-000-9053 Domestic Return.Receipt ±. Town of Barnstable Barnstable d Regulatory Services Department Pj4wmftp � Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1520 0001 2273 3272 March 31, 2016 Jeffrey R. Beausang 140 Crocker Road West Bsrnstable, MA 02668 i ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 • The septic system located at 140 Crocker Road,West Barnstable, MA was last inspected on October 26, 2015,by Matthew Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool You are ordered to repair or replace the septic system within one (1)year days from the date you receive this notification. 0 Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas Mc ean, R.S., CHO . Agent of the Board of Health Q:\SEPTIC\LEETERS\Septic Inspection Failures or Future Evl\140 Crocker Rd W.Barn Mar 2016 Town of Barnstable ' �w�rtsrAet.E, Regulatory Services Department' ' �,e i639• ,gym Public Health Division 200 Main Street; Hyannis MA 02601 Office: 508-862-4644 Richard Scab,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6,-2007 - Rev. 7/6/15 DEADLINES TO REPAIR-FAMED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"e marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA. ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS of cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑A iy portion of the cesspool within'a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water.quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) q Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) OTHER Repair deadline: WSEPTICUEADLINES TO REPAIR FAILED SYSTEMS.doc f Parcel Detail Page 1 of 4 THEP / Wk NIA V sny IwIINS, a) f Logged In As: Parcel Detail Thursday,March 31 2016 Parcel Lookup Parcel Info D Parcel ID 110-024 ,._..�...� ( Developer,,LOT 101 Location 140&ROCKER ROAD I Pri Frontage 1314 f Sec Road� � Sec Frontage Village WEST BARNSTABLE----' Fire District W BARNSTABLE I Town sewer exists at this address NO Road Index 10379 � � Asbullt Septic Scan: Interactive ' 110024_1 Map Owner Info Owner BEAUSANG, JEFFREY R& ERLA G ) Co-Owner F.._._...,m... Streetl 140 CROCKER ROAD f Street2 � � � City AWEST_BARNSTABLE �M! state 0A" zip 02668 Country f Land Info Acres V1.04 use Single Fam.MDL-01 zoning RF -'--. Nghbd$0107 _—1 Topography lLevel Road Paved utilities 1Gas,Well,Septic ( Location Construction Info Building 1 of 1 Year 1988— "'I Roof Gable/Hip j Y � Exc d Shingle Built Struct wall Living 1592 - Roof{AsphlF GIS/Cmp AC,1None Area Cover Type Bed Style}Cape Cod A� wall Drywall �I Rooms 5 Bedrooms wnK° Model Residential Floor tHnt ardwood R oms2 Full-1 Half Grade Average Plus Type Hot Air Rooms i6 uAf Heat Found-f"""�r." "_., AGAR° stories 1,66 Fuel Gas anon;Poured&onc. � r a z 2 Gross 3667 74. Area • Permit History Issue Date Purpose Permit# Amount Ins p Date Comments 5/9/2011 New Roof 201102341 $6,500 6/30/2011 12:00:00 AM REROOF STRIPPING OLD http://issgl2'intranet/propdata/ParceiDetail.aspx?ID=6318 3/31/2016 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s wM 140 Crocker Road Property Address -.i Jeffery Beausang .y Owner Owner's Name information is required for every West Barnstable V Ma 02668 3-14-16 _ page. City/Town State Zip Code Date of Inspection W Ch ds 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 v l ,�Lf�z f on the computer, l use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 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. 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 3-14-16 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �O Us Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is. West Barnstable Ma 02668 3-14-16 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) i Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: criteria ❑ I have not found any information which indicates that any of the failure c teria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts �f Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 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 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is West Barnstable Ma 02668 3-14-16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1O,O0Ogpd. ® ❑ 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`Oyes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 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 t5ins-3113 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 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: "Well Water" 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 y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 5 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for everyWest Barnstable Ma 02668 3-14-16 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: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 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.): Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 101, t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4'M 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668- 3-14-16 page. CityTTown State Zip Code Date of Inspection Do System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26 Scum thickness Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in wo-king order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of const7uction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): i *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 ^M 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 page. Cityrrown 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 11 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.): D-box was backed up at time of inspection. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was full into riser at time of inspection. Leaching must be replaced. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every west Barnstable Ma 02668 3-14-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 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 FRONT ;Al-` 9' 8142` A2•35' 82-48' DRIVEWAY 2 II III t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road 'M Property Address Jeffery Beausang Owner Owner's Name information is required for every West Barnstable Ma 02668 3-14-16 page. Cityi7own 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: >10' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan of house to left of 140 Crocker Road at same elevation shows no GW @ 10' ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH. 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 • r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 140 Crocker Road Property Address Jeffery Beausang Owner Owner's Name information is required for every west Barnstable Ma 02668 3-14-16 page. CityTrown 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 Town of Barnstable. P# Department otRegulatory Services g Public Heal I Division Mate 31m r ? 200 Main Street;H�nnis MA 02601 Date Scheduled /)t,/ /4* Time M Fee Pd. Soil Suitability Assessment for SewLe lhsposal Performed By: ! vtr;messea ey � +^ s04 i ' t�• LOCATION&GENERXL INFORMATIO' N � LocationAddress'.��f(� C'`p � QL� Owner's Name J�y ��GG�/��,1//� _ fGl�1�l CL Address • G�•��C/!�'/ fir'✓ �7 Assessor's Map/PWA: ° y7�� -/Z Engineer's Name � S� PG/4 NEW CONSTRU�'I70N REPAIRTelephone# —-27 . -OQ�� Land Use / D S �( !'1; �l Slopes(%) i Surface Stones X* / Distances from: Open Water Body R Possible We i Area" %�"�ft Drinking Water Well rG ft Drainage Way ft P�opetty Lini z ft Other it of lot,exact locations of tet holes&perc tests locate wetlands in proxifntty to holes) SKETCH:(Street name,dimensiods i • f 7c Parent matedal(gedlogic) QS4 Z6:;lk4 e,0/ Tl/ Depth to Bedrock /A • l, Depth to GrorradwaRer: Blending WaterIn Hole: K[��— Weeping Anm Plt Fatxy Estimated Seasonal11lgh Groundwater ��'/ �' D RRMIN TION FOR SEASONAL HIGH WATER TALE Method Used: ' in es: Jn. Depth abperved standing�in obs.hole - Orotindwtrter AdJusttnent ft. Depth toiweeping fivm side of obs.hole: ��Adj.thetor Adj.Cmundwata Lavel.,,._, Index Well#.^r, Reading Date: ex ell level..�..�... PERCOLATION TEST . DAN 74ne Observation I 7'Inte at 9" V,;L -.------ Hole# Time at 6" a ..._..... Depth of Pone 'JO=--- ' 'lima(9"-6") Start Pre-soap'lime.0 �— - , End Pro-soak / Rite MtnJlnch , w"=�---- Additional Testing Needed(Y/N) Site Suitability Asscpsment: Site Passed Sit.Failed. Od final:.Public H411h Division Obsetvatiol Hole Data To Be Completed o11$ack - g ***If percola ion test is to be conducted within 1009 of wetland,begin i>nninn t first notify the Barnstable C4#servation Division at least one(1)week prior-to g� g DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil ' Other .surface(in.) (USDA) (Munsell) Mottling (Sttu W1%Stones,11041 els. .; Consistency,%aravell 241 ��'� '' � �i� Sal �•• DEEP OBSERVATION HOLE LOG Hole# 2— Depth from -Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. CousistencX. P � 5� o Q SQ o 2- 6 C DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil , other Surface(in.) (USDA) (Munsell) Molding (Structure,Stones,Boulders. ti DEEP OBSERVATION HOLE LOG Hole#1 Depth from Soil Horizon Soil Texture Soil Color Moil Other Surface(in.) (USDA) (Munswo Mottling (Structure,Stones,Boulders. t Flood Insurance hate Mau: Above 500 year flood boundary No— Yes Within 500 year boundary No—LZ Yes Within 100 year flood boundary No V Yes Depth of Naturally Occurring Pervious Material Does at least four feet of oaturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with ' the required training,ex ' e and experience described in 3:10 C1VIR 15.017. Signature Date i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 140 Crocker Road �M • Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 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 314 (,50") on the computer,use only the tab 1. Inspector: U key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. rQ Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 City/Town State Zip Code 508-477-0653 S 14595 Telephone Number License Number 1 B. Certification ,...E 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. TliWinspection 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 15340 of Title 5(310 CMR 15.000).The system: J ® Passes ❑ Conditionally Passes ❑ Fails t ❑ Needs Further Evaluation by the Local Approving Authority 4/7/11 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal stem•Peg 1 oflt7� 4 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W.Barnstable Ma 02668 4/7/11 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 Y day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® 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-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 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 e DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 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 , 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: August 2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form al Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M , 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 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: 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): 1 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G1M 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 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: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 3 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: 5.2x5.2x8.6 Sludge depth: 6" t5ins-09/08 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 ,.•''� 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W_garnstable Ma 02668 4/7/11 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 32" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour 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.): At time of inspection tank appeared to be in good shape tees present no sign of back up. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is W Barnstable Ma 02668 4/7/11 required for every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appeared to be in good shape no sign of carryover or backup. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in good shape no sign of staining or hydraulic failure.Water level was 4 feet down from invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 • Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W.Barnstable Ma 02668 4/7/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 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 A � CaPrQAb� ape 4 `la FS-T 36 ' p B2y y4 , 133 CROUEP— -e-OA-0. t5ins•09/08 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 M 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: • Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Crocker Road Property Address Robert Glick Owner Owner's Name information is required for every W Barnstable Ma 02668 4/7/11 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 lei COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC 1 3 '\ ONE WINTER STREET. BOSTON. MA 02108 61 7-292-5500 WIWA.41 F.WELD D�y logy TRUDY'COXE Governor ytiOA I , 'Se*tm. ARGEO PAUL CELLUCCI DID B.S7RUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 6rnmissioncr PART A n CERTIFICATION Property Address: )`I 0 C Locke f RZ , W,t301_A)S 4_aW-P— Address of Owner: S Aryl E Date of Inspection: G//3/1-8 (if different) Name of Inspector: t j i l I IQ,M /. 4a dde,j I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: lv ee n Mailing Address: P6 027 Telephone Number: 'O25Z 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: _L_/Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office 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 authorir . INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: V/I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. 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 Compliance (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 exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (ravisad 04/25/97) Page 1 of 10 DEP on the Worid Wide Web: http:/twww.magmet.state.ma.us/dep 0 Printed on Recycied Paper 1. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A y CERTIFICATION (continued) Property Address: IqD CrOC ke f Rd Owner: 12 rto.,J (sn C1 Date of Inspection, B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ 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 15 NOT FUNCTIONING IN A MANNER 11 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (raviaad 04/25/97) y Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: j y o C COGk,e r 12 d Owner: 113rlCt v GrT ay Date of Inspection: ��l 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 into 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 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. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality 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 above: 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'll 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. tzsvisad 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: NO Croc <e r R d Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or'No"as to each of the following: Yes No t/ _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. - _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _✓. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / 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 System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: )y0 C roae,r PC) Owner: Q r-1 ao &ra ctx Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: , 11 y. R.p.dJbedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Z. Garbage grinder (yes or no):�[ Laundry connected to system (yes or no):4— Seasonal use (yes or no):S' Water meter readings, if available (last two (2) year usage (gpd): A/ Sump Pump (yes or no):IL- Last date of occupancy: C(.4 2QEN COMMERCIAUINDUSTRIAL: Type of establishment: - Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sour a of information: 24/r,es l� /0 V2arS System pumped as part of inspection: (,yes or no)&- If yes, volume pumped: gallons Reason for pumping: TYPE 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) VA Technology etc. Copy of up to date contracts' Other APPROXIMATE AGE of all components, date installed (if known) and source of information: ;4s-kul LL daho Sewage odors detected when arriving at the site: (yes or no)14 (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1q 0 Cr-OGke r `,�— Owner: ?ria.-) C-may Date of Inspection:. BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron 140 PVC_other (explain) Distance from private water supply well or suction lire D iameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: " (locate on site plan) t u Depth below grade: 3(0 Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 8`X'�>'x Sludge depth: 6_8" �� Distance from top of sludge to bottom of outlet tee or baffle: 3O Scum thickness: 2_3,t Distance from top of scum to top of outlet tee or baffle: f '+ Distance from bottom of scum to bottom o outlet tee or baiYle: � How dimensions were determined: +.Sf lof* Comments: (recommendation for pumping, conditi n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 1 Q.0 k l iU SaQc� GDNd) yin) GREASE TRAP_: (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: (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.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I y rJ Cro C-kC� a Owner: C71 CI.N 6-may Date of Inspection: 6/13)9S TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) u{p!� WOw Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Ok PUMP CHAMBER:_ (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.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: I y 0 C roc k>zr R cL Owner: 'S f iaj 6-racy Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number. leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (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.) (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: NO Crocker lz d Owner: 12 rcc,,j GrardY Date of Inspection: 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 P� (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: IY 0 C rU %r d Owner: gria j GrarlY Date of Inspection: Depth to Groundwater 12+ Feet 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 Use USGS Data Describe in your own words how you established the Hdgh Groundwater Elevation. Must be completed) e rr� d oti 3 30, 3 did Hof �etiC,0Lt1U4-er Tes f p�-�'P � �e l , � wG4-er a+ 12 fe- Lie +(a,,) i- s loc4 4-ed aParox1w,':UWy 3 0 D fee+ fly Ivor f�• s� "s c��,rdx�r-�� � (revised 04/25/97) Page 10 of 10 I AsBuilt Page 1 of 1 �v 17V v TOWN OF BARNSTABLE 1L LOCATIONi 2J4SEWAGE # 7- • Ic.h O VILLAGE`C>. Q�/}S�(�I�_ ASSESSOR'S MAP & L 1�0f INSTALLER'S NAME& PHONE NO. Cl14 COn S-+. SEPTIC TANK CAPACITY LEAC'fIING FACILITY:(type) tit f (size) 'QNO.OF BEDROOMS J' RIVATE WEL OR PUBLIC WATER BUILDER OR OWNER lk. dal (r'ACi U DATE PERMIT ISSUED: /D I — Sr? DATE .COMPLIANCE ISSUED• VARIANCE GRANTED: Yes No w s � I r I • i C a o C http://issgl2/intranet/propdata/prebuilt.aspx?mappar=110024&seq=1 4/4/2016 TOWN OF BARNSTABLE :fit 7 �v LOCATION SEWAGE # 5 7- la a✓� 10 VILLAGE,�Q�S { j�� ASSESSOR'S MAP & L ZI$t . INSTALLER'S NAME S& PHONE NO. e$'14C6-'1 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) `Ti f (size) NO. OF BEDROOMS RIVATE WELL OR PUB/LIC WATER BUILDER OR OWNER G DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: a r lG _ S- 7 VARIANCE GRANTED: Yes No r w C� 3a i i P, No... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ............... ...................OF......................................................................................... Aplifirativit for Dispaiial Works Tomitrartion ramit Application is hereby made for a Permit to Construct (X ) or Repair an Individual Sewage Disposal System at: Crocker Road Lot 101 ............................................. ...... V..... ...... .................................................................................................. Lote Brian R. GradyLocation-Address ee 51 Buffington Ser '*Taunton, MA 02780 ................................................................................................. .................................................................................................. Owner Address . ..................................;.............................................................. .................................................................................................. Instafler Address Type of Building Contemporary Cape 45,214 Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms............3..............................Expansion Attic Garbage Grinder ( ) P-4 Other—Type of Building ............................ No. of persons......._.................... Showers Cafeteria ( ) P4 Other fixtures .............................................................................................................. -3F3u--------------------------------- Design Flow...........7U.0..........................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity__NQqgallons Length. 8" '6" 4_r ......... Width................ Diameter................ Depth................ W .... Disposal Trench—No..................... Width_...___._....__..... Total Length....._.............. Total leaching area....................sq. ft. Seepage Pit No-----1............. Diameter........ZQ------- Depth below inlet........ .......... Total leaching area....?66.......sq. ft. Z Other Distribution box (X ) Dosing tank ( ) Percolation Test Results Performed by._--__-_--ZM2...L9.1at9;KY.-Jr:_Jr ......... Date..............31301.83.......... -- ---------- .....not enc. .......... ,.-I Test Pit No. I......2.......minutesperinch Depth of Test Pit------- I....... Depth to ground water........................ 04 f �Tq Test Pit No. 2................minutes per inch Depth of Test Pit....... ........ Depth to ground water.....not enc.................... 94 ............................................................................................................................................................. 0 Description of Soil.........Se_e..,at;tACLL0d _# 16.52 .................................................................................................... U ......................................................................................................................................................................................................... W �i --------------------------------------------........................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Indi i ge Disposal System in accordance with the provisions of'T'L,:41 5 of the State Sanitary Code—Th er agrees not to place the system in I-i. I operation until a rtificate of Compliance has been issued b oard o N Jd 14 Signed ........... .................. --- ...... 7 ............ Application Approved By................... ............... ...... UDORFER Date ..........! Date Application Disapproved for the following reasons:.......... . Ep ........................................................... .................................................................................................. . ......... ..................................................................... Date Permit No........a_-.2-------- Date.............. Issued.................. ................................ ` 3,Ll THE COMMONWEALTH OF MASSACHUSETTS BOARD . OF Off' HEALTH._ -' -; Town . Barnstable ------ -- ----- ------------- OF............. .....--......_............................................................ Appliration for Disposal Works Tonstrnr#ion Prrmit 4 .. Application is hereby made for a Permit to Construct (�,) -or Repair ( ) an Individual Sewage Disposal .System at: Crocker Road Lot 101 ..............................................••--••---••----...-•-•----•---.....----••----•-.... ............................................... • ...._..........-•---•.._......._-•--•- Location-Address or Lot No. �.ri.an...... Grady. .. 53 Buffin......... -------••----- --................ -....--.... Owner Address W Installer Address UType of Building`:,Contepporary Canoe Size Lot... 4 5c21 -----•-----Sq. feet Dwelling—No: of Bedrooms...........3...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of B.uilding _______________•__---___---- No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------------------------------------•-••••--•••-----•--••-•-••--•••-••••••-••-•--•---••--------------....-•---......_...•... W Design Flow..........�10................:..........gallons per.person per day. Total daily flow---............_330............:--------gallons. WSeptic Tank—Liquid capacity.I.M-gallons Length-_8.g...... Width.....:.:........ Diameter................ Depth.... '........ xDisposal Trench—No..................... Width ..........Total Length......:_:..=........ Total leaching area....................sq. ft. Seepage Pit No....1-------------- Diameter........La-------- Depth below inlet.......6........... Total leaching area...2.6k.......sq. ft. z Other Distribution box (X ) Dosing_tank ( ) Percolation Test Results Performed by.........E6±1..Lantery..J.t:........:.:...........:... Pate.............31.12102.......... a Test Pit No. 1.....2---------minutes per inch Depth of Test Pit------1,2°....... Depth to ground water_A©t...enc..-_. fs, Test Pit No. 2................minutes per inch ,Depth of, Test Pit......: °...__. Depth to ground water_nat_.enc:- O E4scription of Soil........ _.- .e0...attaoed.lak.'D P'k...9Z65? ----------------------------------------------------------------------------------------------- W _ f� I Uature of Repairs or Alterations—Answer when-applicable________----------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------------------------••.•---- J Agreement: The undersigned agrees to install the aforedescribe / e Disposal System in accordance with k, the p 1011 5of the State Sanitary Code u g ther agrees not to place the system_ in _ 4 G, orat�t{ i a •ertificate of Compliance has been-iss t of_ > U Signed: ----•• -• . .----- --••.11J•-• .-• -•.....1..........•-- 1 Date Application Approved By--•-•••--••-••---------------------------------------. G1S.Tti s Date �PPlication Disapproved for the following reasons:---------- ONA1- --•-------•-•....--••-•--•------•-------•--•••-----•--••---•-••-..._...__. 7; .........................•-•-•--------..............-------•-•-------•--------------------•-----.....------------------. --------------------••------ ...............--------------------------------- Date PermitNo......................................................... Issued_........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .fie.. -�-�. .V7C ...........................O F..................................................................................... . (Inrtifiratr of fontplia"r k THIS IS TO CERTIFY, That the Individual Sewage.DisposalJS7stem constructed ( ) or Repaired ( ) by....................................------•--••�..............•----•--• ---------------------...-------....................................................................... '0 ) = �1 f fin_` Installer at.•----•---•----•••-----••......------••-••--------- -----•........-•-•----•----•----•--------•----•••-•--•--•---•••---••••-•----••---••--•••----•-•------------------•---•---.............-•••----•- has been installed in accordance with the provisions of i i _ 5 Xh(�State Sanitary Code as described in the iapplication for Disposal Works Construction Permit"No......................................... dated.............._ f THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. r DATE.....................) C2.-------- :...... �.....'......••---- Inspect THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q, ..........................................OF..................................................................................... \ro..�7----`•3-��. FEE:........................ Disposal Works Tonstrudion Orrutit Permissionis hereby granted.........--------------•---------•-----•-•-----------------.•.....------.....----..._...---------•--..........------.....••--..........._.... to Construct ( ) or Repair ( ) an Individual Sewage Disposal stem atNo............................................................................................................. Stre as shown on the application 4 fq tDisposalrANT ics Construction Per it ................... Dated.......................................... 1 J Board of Health _-- DATE........... 0 T...eK........ 7---------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS Massachusetts Water Resources Commission/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOCATION /_ ) AQ Address—A O L /O/ O ' /� 11 cam! X City/Town G.S.Quadrangle Map ' .v Grid Location Owner r���r4—r" Addressf/ uEp .S 7`ilh ✓ 0.2 7 O G WELL USE CONSOLIDATED WELL Domestic Public ❑ Industrial ❑, Type of Water-bearing Rock Other Water-bearing Zones METHOD DRILLED 1) From To Rotary(type)Cable ❑ 2) From To Other 31 From To 4) From To CASING ,f Depth to Bedrock Length Diameter Type S7�vE L UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials. ''//�� � Sand: fine medium coarse Feet below land surfaced` ❑ ❑ U^, Date measured g 7 Gravel: fine❑, medium❑ coarse❑ Screen: GRAVEL PACK WELL 1 2 /I J Sloth d length a.� from to Yes ❑ No Split Screen(or 2nd screen) WATER QUALITY TESTS MADE Slot# length I from to Chemical ❑ Biological Depth To Bedrock PUMP TEST Drawdown feet after pumping days hours at GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well.or water) Materials From To DRIt-LER t Firm Mora wen nniy LI fZS lc3e AddressP.O. Box 430 �➢ d ��-^ City Registration No. . d Operator's lgnature ease pant firmly f 10M•8181.164843 _ .� '• } '.�4"�4..,p..-., -0.:` •r -`•"5 r +,"'+ t i-Y .yti ,�Cnr{ 3 s;S'.'= + ,e••wyr 'tii ` l m£ti sd,ft,,'yy?� j+„��;•,tav x �.; t 4 ss .� r � sy,, x',� x �a r,r.:« .*r.� R: }ems' � }�"� .•. +ct �f X r �. kr •- :• a ' $ ,l tyt 5rfi+*� Log „Number,; ` ' `� Bottl a '# E`821 Date:#. May 28 B^Q ,.,�a*�"i4� .+,' 1 t `.. , rs �q .. rt ,,L.. ,.. .. :;. .. .. _.:;..• _ -- _s,, w� ��r sk`d �� ° , BARNSTABLE.COUNTY HEALTH AND ENVIRONMENTAL DEPp.�ARTMEN;1'F���" •t: �� sr ��! r" 6x•i'f`''f` -0 , $ t '{Kt r9r;"a'rn f '!•i. F.J-t'+r'rf�1?'r +,lP-}"7 '}}`f„' fr., 74_1 .tY3•'�`' *' 1 ,t a•,r—s SUPERIOR COURT HOUSE""" g � fi ar BARNSTABLE. MASSACHUSETTS 02630tkV ;ys t a' 3'3 rr a :,u e z+•' ,,j•,� K4 ..q` - i a aA j'}g 4'-4"pKi dF SAS$ 4+x a < . tY r DRINKING WATER LABORATORY- ANALYSIS. , ^�^-d rnoNe 3622511" k � r.* 3 # t Si' � �;"y t .•' { s >t 8 i 2 'f`i� r• '�ti :S i,: J,F. r'r: .,3 iie ,; .. � r E%t+3371 `3.773�9 !'•2arj' �;yYyf,•(.#�id i',-�,S,F:..t�� yf'°c.��•, '3sta r# :a. An `t tJ;y'� s.,yra eJ' •'i � •( ! ;t:. .,y.e.7 t� 1+F�i}��.f }•;, t' t•� �i �` t -Cl ienta IiMll rs, ,r .I }:Brian Grady ,;tga + y_� Uf Col lector: Fred.C1 afford c^y .a' i .i.Jr '�(xi` - 5 7)t ,fafaf f"f t'r'a w r'7J�,';� 'e5.'r Mai l i n('�x Address t•J =3< u nQ omr 1 7#� •.`Elll" F t�.S7�Aff -i a�t��n1.t.L rl�Tu .> ! r , Yj T'Ef S�.r1� /L lf�ff s � xz'fkffi �i c F1S2� '!? aunton yi" s9: �. rza n1017 3 r tJ�€ `t 'anii??r�t3€s ,l ime. &`;Date of �,vLL i c + /` ik f Q7 a t tt r t 7 . v a� i f 4 f? i " Y t �i 1 ��3 i✓ l.o�'l�ctli on. f/? yfh li3 Jr5�2/�OJ ,trB.00ama x gf�� �r P r T e of` Su 1 e r.Te1.e hone:: t ; ~R+ y :. ,; Ty t; PP Y' �� � _° a � � ...Sampl:e, Location ot`° Croc er Rd. Wel lDepth. ` .6 c .i4"Barnstab .4 ` e, MA Date�,ofPAnalysis 2 , pm' 2 ? � t •.,I ., � '•;. n T`J ;-: � 1 ri•[ >, ,y:r, a r t:.., M , ^ te, '^`•' ��`Zm{f z�. ist�►,aPrPARAMETER'1,,tw�,:.. f�{;'= Y ;:fir+=t'SAMPLE RESULT ND Dr y p r•";r RECOMME E LIMIfTiS; ** � mow, +t �• •p;;l, :� .'eLi•� �u�.+ai J 'ri+••r s,is3if'S°�P :F;.��trl ��.rt t fax NISI s.r5 kS��7;`� �d'S�4• =�d�?�'f 4i:?.k�.:� 'f'+ 9��' :''�'. '�' #Yry :r;� ,q'�. sfi ".�•y°-It,#e ir�'+_yR,th�,i'st' Total Coliform Bacteria 100 ml # '� / i ✓:; r,,:{ _ o s U. Wit, t r'`•#� 4 AtUU�"'"y<•s :^>'ysa�-r �.;��r s•.e c• t:i. ...♦;�a., ca rf{,_ #ex't� s +♦4 xk'wS.;:ro- r'x;3:1sLt"sa rJ a'a ,S.':t.r�•4:.•4' v.1,lt' �x„wxk' •z°e«f-;^' r a... • 1 a`` €t•�+•?a:. a�y r y:d c ar t-tM.`y y�r t �Jtysk2 i t `6 0 H '�•.:� r, SF.�� a ..Y A3.+�",;' k k a y.t f' yr y �`r rt.• 's' -ti; ,•�ft4- `f-'.t �R a.*.'�s' Conducti.vJ t :'(mi cromhos/cm r .v'if j+ lyr Y } q ` ,+,`+�,' ti J t inJ Tr x 1}gYt _ 500 0 + 7 > � 3 s� y�ef x ".f 5 4 Y i 'f' Y a kr.; r •1 1 f � ::+>'2 h ? ; ,r 'Iron m }�i f'8 x r'. �, • Y= ` t `, 2 ; . 0 Wl a `.z �L :?'i fr l 1 t14 y fl f, ?. 0 3 y fii§ iyxKr, 7 Nitrate-Nitro en m 0.�2 10 r0 r iY15 / r at+ t 9.. Sodium , m) <fat: 20 Ori •w r< 4•�. ' �r� _ r. , � r f�, � f.c 7x5{tj+yf�'1}+�{• yi+4s`t,a.{. 3���?d r �'� t sti ' •rYm t`�v. tr F..,; t ,h•}f{y �.. }t[� Et ts,('/.: , • s, ,. '4 r+'> r t c a i'.y v y i`i'X Art r,y'"',CPC re a,q "� , !IIf f a r 3 i'- - e , : ..•.•!rn i ` . .!'., ���� +C e1 l fr` qd�� r fa. x L. XX '- Water sample meets the recommended limits for drinking of ,all above ',tested parameters`�� �' toe•'h tl.� S s•"§ r'_ '� .:•, w ;, _� •,•. - �r.Rl rl rrri�'} fir ' FY ;v 'f II y l Based only on, resuflts of -the parameters tested for.this sample, the water Is ., sui^tabl e for ndri nkii ngi,but,(mayi pr.,e,sentAhef,,prob.l ems, checked,, below 4 1 } + '-;y1 ry ,•tJ'�-hi �� :'Ut-cx rf �' f3 rkt�,.k# j1'SS j, d' �f.i�.si54�if +,..a aTlf rt`�.i.:i i,! A, 9 ,11 fix. .':.. • S�.w t'1�:x4#•rak..tr r a , { A 7 6Jater.,xs amp hes :hash;�gher<than.:average 3.;l:evel;s -o:f Ni trate f; Future.;moral torsi ng�i�st v� irecommended (2 3,times per year).';to establish any upward .trends. � . J t 4 oz 'e . ' ,tx d Jf b f',�'.�}4 r �4-J..at i +�� 4k et�} f .` :;i.. � ,• .r .', ��'°. i g -7' �,e .w' •S'��*'�3'+��i w J B The 1 owapHz off the water may,shorten the 'useful 1 i fe of the house's Bpi umbi ray tr •s, •Z�, t {° '.'ts J'`c+t�."t yr""% t t 'r-;c: ;. .. i'' '# •x } ,. a,r�hj„'`�vr.. . C .- '4Water tmayi presentiiaesthetic =probl ems;t.(tas,te,,.odor, ,staining) �due.,to: ;, � ;fir {+>r e y - + �• �3�r;��t�k`E�fitdtr+�,�'�� .'1�.�,t�i' ,: 'q�7.�t f '� iwrM' � r:• �i � �"3 x',`d�S".d.J�;? t' {�' ..t , a � a p.;�c. t.L�, r �t� ,� f+'�p t• ;r .' ✓ 7'i i t: t a6x"•'+ 5 j � f r,r � s #' 'h �.,. .� � f{ l° !" •�,� 3 i� D's•L�f s"[ ,.x �r'� T ei.i�./tt � y»t`�..• r + ..� Na.,4R •c ti .,bra a,.t.•_qN rL q _+ d f c F f Y s ..y,ry < �, +:t r xr i ec ',t r M f ,�++�•ygp,a't<t�,�rY ; • r,•s'v 3�i ?k t �" fE`+°Y7 a _+ f D w Water sample" has 4h'i gh levels. of sods um. Persons on low sods um :diets .should h�W,� W ����yy� �'•r`. r r 3 w4. „2• s r;+ �,, 1 r k 4 r'i r '„o a r r E y. y zr%: " y.,c t `" ,t-i• �,R . � � Jd'�1'd a .'r ,i c �i g - c.' ' ...^y r i�r! F .'.:';Yy 4. Yi!'t•��fii.,^' �" {ars i� �e „ „2+„•.r",r#+,i rr aYJ��4»ar.;^+•.'}��;vi DhE L,uu m.e,�.re3^.wa;d4f, .t£tn•do J•«.cMfrt�oo'}'n4 n•yas•r�u,°.et+myp;k'j..t;.•}•Y io+?9 n ,.F A�Af a.�k'z=,li,rtT Ne s:`_�� ] ,.t; $7 1 ,.r 3t,r 7¢t .fiJy. a4 ..}a F-.a z }t r''r c .q. ; s� is}unvftlrit"rc'feFo#-:r.•:.'r J+r;Ak aeor more; of the reasons checked belo rw sample IV-,'?B High ,Nitrates ; q �ff ; �7•ia k�., 3 r$ s }r ; `' -Ij f �a;%� �^;raixsd`'�X 3'r'`r'r�'-9 t.,�,'.t''it � P'`=J Yi }r>�`ti` aR -(9.1f ,fE�Y r' __•!if ,i i • ti}:..W�..t ,.'{ t,+� .-.1t-s eif, },ay F£�! t� 7,� �.,. :A sY'f x'��.'�s � REMARKS x �f •' ofd SSJr 'ai(t� (>i Ft iJ Fa „k;t!j if { Ja f} ) pykr a.� t r 1 t i ig t Iti .ta a t t T w+ 4� � iai �tY its ran y •z r f..,.a r X.' f .,r v ..� + t•a r 'iu }•Pr � r a,.,_ t :. of _: •' r rr ..2i a; � x�,.:'{� ' .,+�a �-., „t ACC k$ ,Barnstable Board of-Health + ffordWel �Dri l.1. 4': •' ,.- <:, a•,rS E +�,°''+ �ti._4 apt :.. t Cl 1 1 l:i rag s i .� v ^ 'Labaratory Director �:�"+ J APPLICATION t FOR PERCOLATION TEST ANb OBSERVATION- PI" . NO.jCD .� � � T I ON_ G o: /0/ •eo�,r/Z •� DATE AGE '� ��S T�3L ICANT � .t� 1�. iZ9� �/ FEE � TELEPHONE NO. (Non=refundable)+ NEER L TELEPHONE NO.Z7,P-O,a-t' SCHEDULED $'- /e:• �'7 /.o.w� (Applicant' s signature) . . . . O • • O O • O . O . . O • • O O • • • • • • • O O O . . . • • • O • • • O • • • O • • • • O O O O • • • . • . a • O • • . SOIL LOG -DIVISION NAME ,f / L /rc ►�/ DATE_ S- /?.-�� TIME .NSION AREA: YES INO � �/- �i< �✓� ENGINEER ?: ' i WATER PRIVATE WELL BOARD OF HEALTH EXCAVATOR 'CH: (Street 'name,etc. ,dimensions of lot, exact location of test holes and i 'Percolation tests, locate wetlands n proximity to test holes) NOTES: • 'jj ;•✓,vim 'OLATION RATE: /'7 e ' HOLE NO: / ELEVATION: TEST HOLE NO: ELEVATION: 1 ►e? � Svt3• l 2 2 3 3 5 7 , 7 8i 8 . 9 79 10 10 11 11 12 12 13 _ 13 14 14 ' 15 15 16 16 / 'ABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS y LEACHING TRENCHES y JITABLE FOR SUB-SURFACE SEWAGE. REASONS:__, ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED. ON PERC TEST APPLICATION ;INAL: COMPLETED IN ENTIRETY By P . E. AND RETURNED TO BOARD OF HEALTH RETAINED BY APPLICANT Railroad OCUS ASSESSOR'S MAP: 110 NOTE:No known wells located less 0i ¢N ` PARCEL: 24 than 100' to proposed leach �- f6cility. All surrounding wells Wo ide REFERENCE: P.L. BK. 301 PG. 99 located in field. N FLOOD ZONE: X Town of Barnstable #25001 C0534J (07/16/14) 5 46'p7'28 E e� v 434.46 ^�Jam' `107 . k 'OC or Street C or Street 99 LOCUS MAP N.T.S. _ Lot 101 45,214t S.F. `� LEGEND: 1.Ot Ac. Map 110 ' Be— _ --�\ \\ `— ss—�- PROPOSED CONTOUR Parcel 24 ^° \ \ ss PROPOSED SPOT GRADE 40 - EXISTING CONTOUR X 30.23 EXISTING SPOT GRADE rX off' AM L. y� �/ + ~•� TEST PIT VON HONE + \ _ya_ — 1 0' \ ® EXISTING WATER SERVICE No. 1068 2 WORK LIMIT LINE c eb 120 Crocker Rd I g8 }4i + °� ?. .,,;,s..;. . .- "�" o / ov �o 1 <`L Maximum Feasible Compliance: Map 110 Parcel 23 - J ° .. J.' Ln° `' � Town of Barnstable: a � 1. 18' & 50' variance request, i Exstin 10 s al Q °� proposed 132' & 100' setback o Tank a„te o:,:.. ,.•.I, �R� between Leach Facility and ti / Y Private Wells g 2. 1.17 variance request, Qj proposed 4.17' cover over leach c @.. �•. Pump and Fill s - �.:' . . facility / Failed Leach Pit �i ��� Rh a " .'.. ae 15V Setback to WeX. Over the Counter Variances NOTE: This plan is to be used for septic system purpo es onlyand is not to be considered a property line surve ( vent / P P Y Y•\ 1 1` / w/�Filter 41 #139 Crocker Rd \ 2' y Mop 110 Parcel 13 140 CROCKER ROAD 1 `°` �' z5 �W � / ~� GENERAL NOTES: WEST BARNSTABLE, MA \ �`°i f { � � , J~ �� '�PJ` V e s Jh e a~ —� 1. VERTICAL DATUM: Assumed___ ' 2. MUNICIPAL WATER NOT_ AVAILABLE. aSSOCIateS PREPARED ` \ o`F / v� a 3. SCHEDULE 40 PVC PIPE TO BE USED THROUG OUT FOR: Jeffrey B e a u s a n g , SYSTEM UNLESS OTHERWISE NOTED. sEPnc SYSTEM oEscNs ` J ��a �,� �� 4. ALL PRECAST UNITS TO CON.EORM-TO 140 Crocker Road v AASHTO: -1 320 Cotuit Road , a� Q N W. Barnstable IVI A 2668 + 5. PIPE PI sly 4" PER FOOT UNLESS OTHERWISE NOTED Sandwich, MA 02563 m 3 q / d 6• A ONSTRUCTION DETAILS TO BE IN CONFORMANCE 508.833.0041 1 �o � and Benchmark set: 2'r b WITH MA ENVIR. CODE (TITLE 5) AND LOCAL 9 Magnetic Nail set orange paint o vo REGULATIONS. Surveying by: B- & B Excavation EL.= 94.11 (Assumed) + o° �`^ a ° 10 196 Kettlehole Rd 7• CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES Terry A. Warner.P.L.S Ch rn c 1 kn Rd Map 110 Parcel 12 PRIOR TO CONSTRUCTION. Harwich,"µo 02645 DATE REVISED SCALE SHEET NO. �o ,�et�Qo c ° to we\l (WS) 432-a3os 04/05/2016 1" = 30' 1 of 2 #`8 ,og , tbo — _ - _ oP 5o S� 1 u #gg Crockerr Op 1°. tba ell �15p c� � i Provide Riser over D-box NOTE: All components to be marked with NOTE: To prevent breakout, final T.O.F. Full �� EL. 95.09 ) to within 6 of final grade magnetic tape or similar prior to final cover. grade of EL. 90.83 to be carried F.G. EL: 93.5-94.0f (Cover to be watertight) out a minimum 15' beyond edge Existin �-F.G. EL: 94.4 F.G. EL: 94.5 2---a-Prev of leach facilit ent ondin Maintain Min. 2� slope over leach facility to F.G. EL: 94.5-95.0 y. Exist. invert ° Install risers w/covers over inlet and Min. 2" of 1/8" - 3/4" Washed Stone or Inspection Port within 6" to grade elevation to be outlet to within 6' of final grade Geotextile Fabric Vent with Charcoal Filter confirmed L=15 (Access Covers min. 20 diam. per Code) " 4" SCH 40 P L=38 L-15' 3/4' - 1 1/2 Double Washed Stone • 4" SCH 40 PVC `� Top of Peastone or Geotextile Fabric EL. 90.83 (2%.MIN) 4" SCH 40 PVC io• s `aa as , ia• ®S=0:67 0.5%.MIN eaa�aae 24' Eff. Depth EL. 90.41 ' 12" 10®aaea®a Install EL. 90.0 EL. 89183 87.73 Q EL. 90.66 Gas Baffle PROPOSED DB-3 EL. 89.73 Use 2 - 500 Gallon Precast Chambers H-20 DISTRIBUTION BOX ' (H-20) with Double Washed Stone 4 28' (Install PVC Inlet & Outlet Tees) Watertest for levelness SEPTIC SYSTEM PROFILE ( 4'� Ends, 4'� Side) EXISTING 1000 GALLON if more than one 25 x 12.83 x 2 H-10 SEPTIC TANK outlet EL. 83.45 N.T.S. Bottom of TH-1& 2 SOIL LOG ADDITIONAL NOTES DESIGN CRITERIA 1 Contractor to confim soil suitability prior to installation. Contact Number of Bedrooms: SOIL EVALUATOR: AMY VON HONE, R.S. S.E. #2517 BOH and Design Sanitarian in the event of varying soils from original 3 Bedrooms INSPECTOR: DAVID STANTON, R.S., BOH soil test. DATE: APRIL 4, 2016 10:00 AM Soil Type: Class I PERMIT: #14994 2. Pump and bockfill existing Failed Leach Pit. Any contaminated Percolation Rate: <2 min/Inch PERCOLATION RATE:<4 MIN/INCH IN C1materials within 5' of proposed Leach Facility to be removed. Daily Flow:. 110 G.P.D./Bedrm x 3 =330 G.P.D. Design Flow: 330 G.P.D. Min. Required) TH - 1 TH - 2 3, Water line to be sleeved at any sewerline crossings and within 10' ( q ) EL. 94.45 EL. 94.45 of any septic components, as needed, per Water Department Garbage Grinder: requirements. Contractor to verify location of water line prior to Not Allowed A A Loamy Sand Loamy Sand construction. Leaching Area 10YR4/1 10YR4/1 Required: (330)/0.74 = 445.94 S.F. 4" 94.12 8" 93.78 4, Distribution Box to be placed on 6" crushed stone or compacted, B B level base. Septic Tank Required: 330 G.P.D. x 200% = 660 G.P.D Loamy Sand Loamy Sand Minimum 1000 Gallon (Existing) 10YR5/8 10YR5/8 �-� 24" 92.45 3o" 91.95 Use 2 - 500 Gallon Precast Chambers H-20 with 4' C1 C1 Double Washed Stone: 25' x 12.83' x 2' Very Fine Sand Very Fine Sand a�'1 2.5Y6/3 2.5Y6/3 �r o°,°j`'F�a 46" 90.62 46" 90.62 ' � P�y� moo`' Sidewall Area: 2(25' + 12.83')2= 152.0 S.F. C2 Perc C2 Bottom Area: 25 x 12.83 = 325.0 S.F. Total Area: Medium Sand ® Medium Sand 477.0 S.F. 2.5Y6/6 56" Bottom 2.5Y6/6 Desi n Flow Provided: 0.74 477.0 S.F. = 352.98 G.P.D. 140 CROCKER ROAD SEPTIC TIES ' � WEST BARNSTABLE, MA ' v it-" " 7 , associate 5 s FORPAREo Jeffrey Beausang 132 83.45 132 183.45 fi4 sync SYSTEM DMGNs 140 Crocker Road No Groundwater Observed ' 320 Cotuit Road 12" - 9": 7:22 minutes sandwich. MA 02563 W. Barnstable, MA 2668 9" - 6": 10:40 minutes PERC RATE: <4 MIN/IN. ( C1 Horizon) 508.833.0041 and ��9 by:I, Amy L. von Hone, R.S., hereby certify that I am currently approved by �'�. s„ B & B Excavation the DEP pursuant to 310 CMR 15.017 to conduct soil evaluations and Terry A. Warner-P.L.S. that the above analysis has been performed by me consistent with the Harwich,22Long Mn o2°°dsas DATE REVISED SCALE SHEET N0. requirements of 310 CMR 15.017. 1 further certify that I have y j successfully passed the Soil Evaluator's Exam on November, 1994. Z (508) 432-&W9 04/05/2016 1" = 30' 2 of 2 I AIMING WALLS ARE SHOW Oh HI ALL CONF/f Kf 7T40N OF CONSTRUCTION IN ACCORDANCE WITH THIS PLAN/S REOUIRED. 24 0/A CAST IRON MANHOLE r'' BECONS7EO WATER T A4 OTHER PER THISCFFIiF 9-ALL BENOT/F!O Pf>�Q4 rOBACKF/LL OFTHESYS7EMFORpJSfGTgV FRAME AND COVER BROUGHT i A MANHOLE CQC01 V S TifON. 57�VU VE AR N Ti'C FUTORE, l T TO F/NI SH GRADE/S REOU/RED /8 U ACCESS MAY R EX TENS1CW OF THESE RETAWING WAL _ FINISH GRADE 111 I' I I 11 111 1 i) I II I 11 11 111111111 1111 1�1111 LNPERFORATED 4„UNPERFORATED Z 2„1/B„ 1/2, PIPE PIPE �AS!'Eu ST01E MIN REODELEV= 47.2 0 2 77 L IOUID LEVEL 3/4,I 1C/-//2 — — 1000,88)�000o) pppp0p OO WASHED S70AC 4Sched.40 2 00O000�r PV.C.R'PE r`nn�a% _ 254 PVC a.ppppppp7EE . ,� 000000 6B O TEE0000000000CrCOG O a TANK /54V0 WIDE 3 OUTL E:TS s / REQUIRED /0. O,, W N -Q40-GALLON SEPTIC TANK DISTRIBUTION N a For proper performonce,septic tank should be //;;{/ GROUND WA7ER TABLE BV/l w \ \ \ \\ \ inspected annually and WW the iota/depth of -- Nl \ \ \\\ scum Q solids exceeds 0 the liquid obpth of SEEPI4GE P/TAND LINER the tmk, the tank should be pumped, PROFILE All topsoil, subsoil and Inpervaus maten04 ifanY,must be \� \\\ ♦\ \� m low the leaching area and to'b -- ` excavated Q removed be 9 WELL �� �.�\ \ \ \\ ems\ \ \ ; distance of/0'feet from all sides of the /eochng area. \\ \ OF 3/4 777 / l/2 �� \\ \ \ \ - WASHED 57OYE ,�\ Excovvle down to 5"below the surtoce of the natural , \ \ \\�\ \ , i t permeable sal. Bock fill as fired with clean coarse sand 4 18 P b "aq" P ACCESS and rove/ free from fines,cloy,organic matter and _ -� ♦\ \ \\ \ \\ UVPERR7RarE0 _ 9 \�\\ ♦ \\\. \ BM NL.SET/N MAN CXE \ \\ \ \\\ •' E ELEV= PIPE large boulders. \ \\ .� \\. \ \ /4 P/N \ �� SO Op ASSUMED 2.17 OF TITLE 5 LL T /W ¢ i �� \ \ REGULATION 44 \\\\ \\\\ \ i ♦ \ NI N \\ \\ b DIA. L/HER 5 . 31► \.\ \ \ DT101 \ . \ \ \ \\ _ ¢s 4 Ex�si� 20 �, ! 1 \ \ ♦ \� \ •� \ \\ \ \ SEEPAGE P/T AND L/HER 4e \ 49, 1 \ \ \� \ \� \ _ PLAN i e \ Note The de n of this system does not permit the use of garbage i� yMOP sg Y p g °g APPROX 5O 6 `` WATER `�. \ \ � disposal units LXAT.ON / \ SER W \\ f \. I [/CJIU►Y No ermonenJ structures shall be conslrucfed over the reserve area. '� \ \ \ EL VAT p sNITARY--�:J E lON SCHEDULE EL EVATlO11/ ,.- srsTEM -> sJ � �• I. r�2 . � � � 1, _ 50 \ \ \ \ \ \ \ u* TO O O N O LEACH/NG AREA DES/GN ANALYSIS I-�' D/AM�TEr/ � �-� -- ` F/N/SHED BASEMENT FLOOR DEEP WITH 2 \ /0�,p 0 GALL 4> -\\ F WASHED SR7NE SEPTIC TANK lU /N/4-P/ REQUIRED O AREA EL EV.-51.98 FINISHED GARAGE FLOOR ON SIDES A \ ASSUMED X6 SF 1 1 1 s r BE Ar / PD/BR=JJO GP0 ` 1 r 1 t SEWER INVERT AT FOUNDATION �� —�—� \ � i � � // J 7 + 50%FOR GARBAGE GRINDER = !/A_GA) o I / / / I J 4 SE6YER INVERT IN70 SEPTIC TANK \F ►, i / / / / �j / t • DESIGN: .330 _GAD rorAL EFFLUENT ,�,�• .,, i \ ., i 7 SEWER INVERTOUT OF SEPTIC TANK _ U.Pa. 9 7 DESIGN PERC. RATE 2 M/N./INCH [l SEWER INt/ERTINTO D/STR/BUTON BOX 7 BOTTOM AREAS.F x /�_ T8 GPD � ' F i t . ✓ 7 1 , 1 dge Of f f l • nl / 1 SEWER INVERT OUT OFD/STR/BUT/ON BOX 46 -WE►�r4LL AREA 8/ 8 S.Fx 2. 50 4T0 GPO ' r / , I r aCfO KE RD. , SEWER/NVERTAT SEEPAGE PITS rorAL LEACHING AREA .266 5F W1CAPAC1rr 0F5 B GPo W r , l 46.80 , . 1 1 ELEVATION OF GROUND WATER TABLE36.8 , h o� �o �o v � � SOIL EXAM/HAT/ON REPORT (P-/�69> h EXAMINATION TAKEN BY EARL LANTERY ✓R. ON 3/30 /9 AND WITNESSED BY ✓OHN ✓ACOB/ BOARD OF HEALTH AGENT ; Ex TEST PIT, NO. TEST PIT NO TEST PIT NO. TEST PIT NO. TEST PIT NO WELL GROUND SURFACE EL 50• / GROUND SURFACE EL.48:8 GROUND SU4FACEEL. CWOUND.SURFACE EL. 690UND SURFACE EL c O 0 0 O I THIS SUR VEY,9 'PL AN WERE PREPARED IN ACCORDANCE WITH PLAN FOREST_DECAY / L I'7 N FOREST DE 'AY THE'PROCEDIRAL AND T£CHMCAL :STANDARDS FOR THE PRACTICE ` / ` OF LAN - TOPOGRAPHY BY TRANSIT STADIA METHOD SUBSOIL SUBSOIL D 9JRVEYING IN THE COWONW£ALTH OF MASSACHUSETTS Z 8 Z 8 2 2 2 REMARKS LEGEND THE SANITARYD/SAOSAL FACILITY SHALL ELF CONSTRICTED INACCORDANCE W/TH THE SAND SAND LOT HAS NOT BEEN STAKED - EXIST/NG CONTOURS /OO —l00 REOUIRE4CIVTS OF 77TLE= OF rHEs7ATEENVIRoA*,-N7AL CODEANDNOVARIA77O1/s TYP F :CONTEMPORARY C FROM 7N/s OES/GN SHALL BE ALLOWED W17H•IOUT PRIOR AP4VVAL OF rH/S Cn-CE. } E O HOUSE P�S6D ON7UNS C]——`"- 4 4 4 4 �j CAPE X Tl - DUE Tn stbc COAO/77GWS,WATER TABLE£LE IgT/ON AND C EPlABLE MATERIAL F0U'VD E IS NG ELEVATION /OOXOO CAN VARY AND MUST Be VER/F/ED PRIOR ro THET1M£OFCONSTRIJ<T/ON. MEDIUM MEDIUM ASSESSORS PLAN NO.//O PROFtOSED ELEVATION /00 TO COARSE _ TO COARSE PLOTN0.24 LOT'NO/0/ i--- 6 6 6 6 ZONING CLASS/F/CA779AN RF FAN/SHED SLV AVE&VADE FLOW-�- SAND, / TESTP/1 LOC4TX.W ^ / p �/ �:-- SAND Mm. Se/boc*s f. 0 S. .1:�_R s + BR�fi/Y R. I T / a a 8 8 e BUFFINGTON ST. TAUNTON I CER7AFY THAT 77/ESEwAGE'D/sms4L FACILI YSHOWNHE7�'ON HAS DEVIGAED INACCO904ACE WITH R£GULA770NS OF 77 E LOCAL BOARD ` OFHEALINAND 777LEW OF7HE STATEEN1VZWMAffWM CODE. /o /o /o /o /0 ON-SITE SAKI URY DISPOSAL SYSTEJI�1' LOT I0I CPOCK R R � y G147F P SS�tANAL £iVGA41fEER E D. /2 BOTTOMA/VO WATER f2 BOTTOM/NO WATER /2 /2 /2 DE3'/GNED BY.BRG µ o ENC. E/1C. DRAWN BY KGH W. BARNSTABLE MASSACHUSET TS 3 I4 /4 .e /4 l4 /4 ° CHECKED BY.•✓-C N,/BR.P M APPROVED Br:✓C.AIVO.R.P HAYHORD-BOYMM8 WILL/AMS INF.. PERC. TEST PERC TEST Pmc. TEST PERC- TEST POK Ms DATE:3/27/87 ENGINEERS SURVEYORS SHEET m TAKEN ATI�, FEET TAKEN AT FEET TAKEN AT "FEET TAKEN AT FEET TAKEN AT FEET cALE/ - 4o 00 VSkWS: SCHOOL_Sr _I OF I . R£ /40 S 00 S . 6i40iCKTON M SS. _• .� _ # RATS' ..�..J1b�V.INCH RATE rM/Al/INCH - RA1`E- _AI/,Y.//MG�1 RA - lw / A - _ w � TE rE�1t /NON R TE AMN./lNCH �, � ; I sb caJRT Sr. TAI�W70N �11ASS. -: -' iL S®PX5