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HomeMy WebLinkAbout0116 DEER JUMP HILL - Health n 116 Deer Jump Hill West Barnstable A= 132-040 ° v WCommo I ealth of Massachusetts Title 5 Official Inspection Forme _ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Deer Jump Hill c' Property Address --------�,,� Cher I Ann I<res e rya Owner --- ------------ --- ------ Owner's Name -----r•,,,� information is required for every W Barnstable ma _02668 4/16/15 F page. City/Town State Zip Code Date of Inspection �a 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. filling A. General Information filling out forms on the computer, use only the tab 1. Inspector: S� v key to move your cursor-do not Michael Di$uo.no keY y the return Name of Inspector -- -------- -- - DiBuono Sewer and Drain /da Company Name -------- --------- - —-- ----- 8 John�ath Company Address ---- ------- — -- ---------- - B S Yarmouth- _ MA 02664 City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number — B. Certification I certify that I have personally inspected the sevrage 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 4/16/15 In ctor'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. 471 t5ins•3/13 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1g1()u I Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Deer jump Hill _ Property Address — — — Cheryl Ann Kresge Owner Owner's Name — — information is - required for every W Barnstable _ ma 02668 4/16/15 page. City/Town 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: The system contains a 1500 gallon tank as well as a concrete Distribution box:All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several Flo defusers trench is 44 'x8'x4'and at time of inspection levels appeared to never have been at abnormal levels. 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. El Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Deer Jump Hill Property Address — — Cheryl Ann Kresge Owner Owners Name information is W Barnstable required for every ma 02668 4/16/15 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 (Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I � Commonwealthmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not far Voluntary Assessments 116 Deer Jump Hill Property Address ---- --- Cheryl Ann Kresge Owner Owner's Name --- information is required for every W Barnstable ma 02668 4/16/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is.within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System.Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 4 of 17 �. Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Ann Kresge Owner Owner's Name information is required for every W Barnstable ma 02668 4/16/15 page. Cityfrown 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 crit eria are triggered. A.copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system_ must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection ,Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any.question in Section E the system is considered'a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 5 of 17 I' �. Commonwealth of Massachusetts Title 5 Official Inspection Form of Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 116 Deer Jump Hill Property Address Cheryl Ann Kres e Owner 9_--- ------- Owner's Name information is required for every W Barnstable _ _ ma 02668 4/16/15 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): 5 Number of bedrooms (actual): 5 ---- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 116 Deer Jump Hill Property Address Cheryl Ann Kresge Owner Owners Name information is required for every W Barnstable ma 02668 _ 4/16/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several Flo defusers trench is 44 'x8'x4'and at time of inspection levels appeared to never have been at abnormal levels. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage.system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage Well water 9 ( Y 9 (gPd))� Detail Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 116 Deer Jump Hill Property Address — Cheryl Ann Kresge Owner Owners Name information is required for every W Barnstable ma _ 02668 _ 4/16/15 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.- 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): l5ins•3/13* Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Ann Kresge Owner Owners Name information is required for every W Barnstable ma 02668 4/16/15 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: 27 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18 "s 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.): System is vented throught the roof Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass 9 ❑ polyethylene' ❑ other (explain) 1,500 gallon If tank is metal, list age: years., Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Gallon Sludge depth: T s l5ins•3/13 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 9 of 17 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Ann Kresge Owner Owner's Name information is required for every W Barnstable ma 02668 4/16/15 page. Cltyrrown 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 24 Scum thickness 3° Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure 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 pumped at time of inspection as well as on a regular basis Grease Trap (locate on site plan): Depth below grade: NA 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 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •y''• 116 Deer Jump Hill Property Address Cheryl Ann Kresge Owner Owner's Name information is required for every W Barnstable _ ma 02668 _ 4/16/15 page. ' CityrTown 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.): Tees are in place and levels are normal. 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 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •''r 116 Deer Jump Hill Property Address - Cheryl Ann Kresge Owner Owners Name information is - required for every W Barnstable ma _ 02668 4/16/15 page. City/Town 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 At Normal Level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution Box is level and at normal level with no signs of carry over or decay. 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 Ofrc al Inspection form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Ann Kresge Owner Owner's Name information is required for every W Barnstable ma 02668 4/16/15 page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type.- El leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 5 ❑ 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.): No sins of carry over. no signs of hydrualic failure 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 f ElYes ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Deer Jump Hill Property Address — — — Cheryl Ann Kresge Owner Owner's Name information is W Barnstable required for every ma 02668 4/16/15 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.): No signs of ponding or hydrualic failure. 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.)-. [Sins•3113 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 °,w •''v 116 Deer Jump Hill Property Address Cheryl Ann Kresge Owner Owners Name information equir for is every W Barnstable required for eve ma 02668 4/16/15 page. City/Town 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 i t S 151ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 g t. cap=;i� Izry rn�it Ir?t�IITIC)k {�st slll SLWAGL4 1 Asscssows MAP 4 OTALLI �7 1NSTA1_L8R"I N All i", �a PI(ONII NC.). 81.1) C. TANK C:AP{"eCITY L} Ac:IIING FACHATiA4 " NO. OP BEIMOC)61111) PRIVATIE WELL OR I bUII.ULIt CAR OWNLI 7 �n ✓�/ DP'I'1i PERMI'i DATE COMPLIANCL 1ISSU$D, VARIANCE GRANTED: Yes No T ,- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 116 Deer Jump Hill 9 Property Address -- Cheryl Ann Kresqe _ Owner Owner's Name. required for is every W Barnstable _ required for eve ma 02668 4/16/15 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: 8+ Ft 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: 5/11/83 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan shows adj ground water at 13'8 ft 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 116 Deer Jump Hill Property Address Cheryl Ann Kresge Owner Owner's Name — — information is W Barnstable re uired fo for every ma 02668 4/16/15 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 17 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every West Barnstable MA 02668 03/01/13 page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection fors may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector. key to move your cursor-do not Michael Kellett r "I use the return Name of Inspector key. Aardvark Environmental Inspections Company Name PO Box 896 �1 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 SI 3742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addre24nd that ttte p information reported below is true,accurate and complete as of the time of the ins,p lion.The nspection was performed based on my training and experience in the proper function and matftenance of n site sewage disposal systems. I am a DEP approved system inspector pursuant tdSc�ction 15: of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails =' ❑ Needs Further Evaluation by the Local Approving Authority b 03/05/13 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 underthe 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-11/10 Title 5 Official Inspection F S urface Sewage Disposal System•Page 1 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is West Barnstable MA 02668 03/01/13 required for every page. City/rown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E Calways complete all of Section D A) System Passes: ,I ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is West Barnstable MA 02668 03/01/13 required for every page. Cityrrown 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 ❑I 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 t5ina•11f10 Title 5Official Inspection Form:Subsurface Sewage Deposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every West Barnstable MA 02668 03/01/13 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 mannerthat 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 El ® 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 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 H Commonwealth of Massachusetts Title 5 Official Inspection Form E Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every West Barnstable MA 02668 03/01/13 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- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria e)dst 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. 2 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every West Barnstable MA 02668 03/01/13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every West Barnstable MA 02668 03/01/13 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/tndustrial 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•11/10 Trite 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is West Barnstable MA 02668 03/01/13 required for every 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of-latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval_ ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's(dame information is required for every West Barnstable MA 02668 03/01/13 page_ Cityrrown State Zip Code Date.of Inspection D. System Information (coot.) Approximate age of all components,date installed(if known)and source of information: 10/13/88 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.8 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: 1.0 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: 1,000 gal Sludge depth: 4" t5lns-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f `r li Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r< 116 Deer Jump Hill !Property Address Cheryl Kresge Owner Owner's Name information is West Barnstable MA 02668 03/01/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official ,Inspection Form 61 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments --.''yr 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every west Barnstable MA 02668 03/01/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 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-11/10 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is West Barnstable MA 02668 03/01/13 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ;t Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every West Barnstable MA 02668 03/01/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers. number: 5 ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/attemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation,etc.): This system has five diffussors surrounded by three feet of stone.There was no sign of ponding or failure in the stones. 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•11110 Title 5 official:trrspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts w Title 5 Official Inspection Form s1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every West Barnstable MA 02668 03/01/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts J Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner .Owner's Name information is West Barnstable MA 02668 03/01/13 required for every page. Cityfrown 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 budding.Check one of the boxes below. ® hand-sketch in the area below ❑ drawing attached separately rear 28 37 48 38 66 55 t5ins•11/10 Trde 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 a• Commonwealth of Massachusetts Title 5 Official inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every West Barnstable MA 02668 03/01/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 4.7 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: I augered to 6.0 feet andfound no water. I adjusted to 4.7 feet. Bottom of leaching is at 4.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page.- t5ins•11/10 Titte 5 Ofircial tnspefton Form:Subsuftoe Sewage Disposal System-Page 16 of 17 L f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Deer Jump Hill Property Address Cheryl Kresge Owner Owner's Name information is required for every West Barnstable MA 02668 03/01/13 Citylrown page. 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•11/10 Trite 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 penvft Number: Daft- Cornpleted by: HIGH GROUND-WATER LEVEL CATION Location:_ t ( 6 e e,r 30 VA C�� 1� Lot NO. ner: ter; Address= . o les• f Oda- to t Ilia ft___. ._.. �_ __...__.___ .._ __._.._�_ A� -FP 2 udog VhMw-Lffvd Row ZMM aid siW and deftravioW OAMloggiaft index well,------------------ � � �__�--------------------- C3 rEP 3 Llsim awn&AY nwart`•ems ; Ream=Lam" wow sewd for kmj=MR TEE 4 thM Table zf WaTer4ewd A* r € for incioc (STEP ZA)i=cures dwth tam kvd€er Ibex sall JSTEP 3L ash nrnae MEP 28.1 :'IEP 5 EWways dwth 10 h4ft yr &fthe kwo add CSTEP 4) Iwo at siliMT801 1) 1& vsY . �n� ►��� mil- ��' J,� . 00 N A. J� J � i i J N� r� a ��jJ ''LL C 7 c WN OF BARNSTABLE KS ' �� Ile LOCATION SEWAGE #_ s VILLAGE�L' ' _ ASSESSOR'S MAP & LOT A " 13dr 0 INSTALLER'S NAME 8i PHONE NO. 2& -14�11 SEPTIC TANK CAPACITY. LEACHING FACILITY:(tppe) . (size) NO. OF BEDROOMS PRIVATE WELL OR BUILDER OR OWNER /�///��/ ✓� DATE PERMIT ISSUED: 17._ DATE. COMPLIANCE ISSUED: VARIANCE G.RANTED: Yes No _ f ` J 1 73 d r 4 r SEPTIC SYS � '���! � No.... �... .9 i.& Fas... s�............ _ THE C0 4JNON.WE-F1L.4;OMAeG1;LCt1AF,,:US B0A GKff H - ...To •1.................OF........ - .........-...... Appliratiun for Dispniittl Works Tonitrnrtinn Permit Application is hereby made for a Permit to Construct (Y—) or Repair ( ) an Individual Sewage Disposal System at: .t:rrC:...a_-_3�> ...J4#Mf'...4.L4........"%-$A? 1. > -------•-------------------------•--------......--...-----••------••---...-•-••---•••...... Location-Address or Lot No. ......................___...................................................................... •-----------•-_......--•---_...._..•--•-------.................................................. Owner Address W ....... ............ ..............•...... -- .........a Installer Address Type of Building Size Lot...( 5,..5_Z.Sq. feet U Dwelling—No. of Bedrooms............... ... .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers f� YP g -•------•------•--•--------- P ( ) — Cafeteria ( " ) a' Other fixtures -----•-----...--•...................................••...........--- •. W Design Flow............110.......................gallons per person per day. Total daily flow.............r..aSb...............gallons. WSeptic Tank—Liquid capacity.14SMIrallons Length.... Width:.. Diameter................ Depth.5113.It.. x Disposal Trench—No........-5........ Width.....9.......... Total Length......4A..... Total leaching area_-.S1:S..sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by......1~: 11� 1�I� ,.�.>ts... ..... Date.�J 1Y��i ... ...'S. Test Pit No. 1....4:....minutes per inch Depth of Test Pit......to..'....... Depth to ground water.......6.............. Lz. Test Pit No. 2.._..�Z....minutes per inch Depth of Test Pit.......to........ Depth to ground water......6. ........... pr x .......0............. .S•...t--•h•i-----....t.-�--..-�.........�..�..--..r'..�..�......�.1..... -4--D------.-q-�-_-.--r�- ---------------,S--•--'--. O Description of Soil.ca° 10 �� .. D.. ......... ...-•U ..�_...�....r.-..L. •----•---••-•. ....G,*1.................................................................................................... V Nature of Repairs or Alterations—Answer when applicable.................................................•.............................................. -••--•-•...................•--------................-------•-•-----•----•••---...---........••-•-•••••••-•-••-•••--------••----•-•--•••----•••••-•---•-•--................••--•••-•....•-------......... Agreement: The undersigned agrees to install.the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LTI.IZZ 5 of the State Sanitary Code— The undersigned f urther grees not to place the system in operation until a Certificate of Compliance has been ' ued by the board of h h Signed. ........... Date Application Approved By•••• ........ .......................................... .......... Date Application Disapproved for the following reasons:............................................................................................................ -•...................................•------•......-......---C..........-•-----•------•-••--••----.......-----•-•--........-•--••-----....................................--------• ............ Date . PermitNo........ =+�..li ...................... Issued.------.........---•---•----------.................... Date No...�.5 _... :9 '`J -- FEa.. `?r ........ . 4 THE COMMONWEALTH i F MASSACHUSETTS i BOARD OF HEALTH. 7pv"'I�'A.................oF=... 1�-,- ...... 5 A V iratiun for Dhip ual Works Cfunutrttrtion Permit Application is hereby made for a Permit to Construct (Y-) or Repair ( ) an Individual Sewage Disposal System at: ......................................•---.._. .......................................... Location-Address or Lot No. ................—....___....................................................................•. ••..................:....................................................................._..... Owner Address ....:......... /........................ W � a --•---•••--•--•----------------•-••••--•....n'sta....... : :. .......... ......_..... . �/ Installer+ U Address Type of Building Size Lot..(23,.S.7._.?.Sq. feet U - Dwelling—No. of Bedrooms..................e:5......................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers a YP g ---...--•----•-•--.....---•- P ( ) — Cafeteria ( ) QOther fixtures .-------•---•-----------•............................................:..-----------•-----.....----•-....--•--••••..• --......... W Design Flow............-r).......................gallons per person per day. Total daily flow............. ...............gallons. WSeptic Tank—Liquid capacity.1 ?gallons Length... Width:S.'��".. Diameter................ Depth.5:?i��... x Disposal Trench—No..........-i-----.-.- Width....._�� .......... Total Length.....4;4----- Total leaching area..4-50.:�..sq. ft. 3 Seepage Pit No......................Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (4) Dosing tank ( ) Percolation Test Results Performed by....._i?:F3��k�'- : *� .,. �:....-...•.:.. ?.__.. Date.-`�-....... �...`a�qa- j ..- ,�a Test Pit No. 1....:!�?�.....minutes per inch Depth of Test Pit......�_Q I........ Depth to ground water......A�............. Li, Test Pit No. 2.....4Z....minutes per inch Depth of Test Pit......I 0 t._..._. Depth to ground water......�3.............. O Description of SoiIG).. . t�aAw,1••-±-q �1t�-Sea.�_�...-, ��-G' x- .��..- -s � ��� � T_."� ,.:�.. .'..� �_., --- (� �.. �.'.._ 7' ?. #.... ! :.... :... t .._. t ram ,.-:- U .....--•--•---•-•--:.....'.....•••••-•-••...•-•.._._....--• _�... ..... UW .................................................................... Nature of Repairs or Alterations—Answer when applicable................................................•.............................................. ........•-............................................................................................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:ITLZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been,,issued by the board , o�f'health/ nedSi . - Date Application Approved BY ��'t'' ��-----.:. .. ------•---------------- ' I Y-----••^---------Date .......... Application Disapproved for the following reasons:s:----••-•-----------------------------------------•---.........--•-•---------•------------------.............__ •^------•.............................•---- ........---------------............--•-------•---•-----.............---....................................-•-------------........... .Date............ Permit No.. --ft---� -�--�•-------------------•-- Issued -....................................................... Date w..r. .................... ...».{n+-}ri.fTO®Ii.............. .'....i............... oTT..._. ..-.S...t ----------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ......................... ...........OF..........Ly.,.. .....-+,... .............................................. (Intif utttr of Tompliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�e) or Repaired ( ) bY------••---.....-•---........-•------------------------------•-----.............-----•----------•---........---.....................•••...._...•--.•-•-• •••••-.............................-- �7- �r� Installer at........AL- ^� �.............................!......-1-.................`......•-----......... ....,.-.-..... ..='`.................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... &._��.p.q............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. I ` DATE.................... ?�� ..... .................................. inspector......................... f r. ti m er.e.........,..o.;aor�.®,�,,- �...,, „-.........»..`�� ---- _nmr�.�.^A----r,..----s—ew,....e......, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF `REALTH ! ..-..........oF......... _��.. - -t NO.. FEE.. ................ u, Disposal Works Tonutrnrtion Permit Permissionis hereby granted.............................................................................................................................................. to Construct (�);or Repair ( ) an Individual Sewage Disposal System at No......... 7................ �e� .p... Street as shown on the application for Disposal Works Construction Permit No.._:.�Dated.......................................... lk U---- =----- ------ DATE....................Il..�.?...:"....�?-•-"-/�i........................._ Board of Health 4/1612015 Assessing As-Built Cards oz/�l6 i I lie QWN OF BARNSTABLE LOCATION (' SEWAGE # W=,32�e VILLAGE / ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. sG 3r� SEPTIC TANK CAPACITY. LEACHING FACILITY:(type) (size NO.OF BEDROOMS PRIVATE WELL.OR F4011111101169M*199 al 4 r BUILDER OR OWNER i�� ✓ ,.9�_ DATE PERMIT ISSUED: 7 /7-8� DATE COMPLIANCE ISSUEDL /b -!3 -� VARIANCE GRANTED: Yes No 1� _ 73 http:/Avww.townofbarnstzble.us/AssessinglH Mdisplay.asp?m appar=132040&seq=1 112 ASSESSORS MAP N0= ^ PARCEL N0: 3 7 "--- Fee------ --=- � BOARD OF HEALTH Qq0 TOWN OF BARNSTABLE I� Lr'tC ' 11 ApplicationfibrVell Cone;tructionA3ermit Applicati i ere by made for a permit to Construct Alter ( ), or Re air ( )an * di *dual Well at: _ g Location — Adds— Assessors Map and Parcel -- - - —- ------— - -- — - - - - — ------- -- ---- ---- Owner Address - ------------ Installer — Driller Address Type of Building Dwelling-_host e ______ Other - Type of Building ----- ------------------ No. of Persons---------------------------------------- ------- Type of Well-4 i PJ e T --------------- ------- Capacity- --------- - - --— --- Purpose of Well&''`-`-`--L ------------------------------- - Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certi icate %�Compliance has been issued by the Board of Health. u��-�J y S Signed - - ------------------------------- --���----------- � • ��-• B date Application Approved _�1 --- date , Application Disapproved for the following reasons:------------------ --------------------------------------=------------------ -----------—-- ----- -- — -- - ------------------------ - -- -- ---------- �,� date Permit No. — ---- 11ooll '�— ---------- Issued --------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (tertificate ®f (Compliance 1 THIS IS TO CERTIFY, That the ndividual Well Constructed (�), Altered ( ), or Repaired ( ) -_D _ .�.�� /�� // D,-,// , _ r Installer — has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit N '`--- ----- -�Gated.' --___'?- --`'S THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE ---- ----- _-- - — -- Inspector--- - -------------------------—-- ---- .� ,No.-�="-------------- Fee---- i BOARD OF HEALTH ,, TOWN OF .`BA N`STABLE I lt �. A.pplicat ion-*rVeil Cootruct ion Permit Applicati fi.�hereby made for a permit to Construct ( �), Alter ( ), or Re'air -( ` )an individual Well at:, f Location —';Adds ! Assessors M~ap and Parcel o� ;t# c l Owner �t Address / --------- - - - -- --- ------- f Installer Driller y ' , Address . �Typejof Buildings Dwelling-h--y- L Other - Type ND. of Persons--------------- ----------— -- Type of Well—4 ` �J ---.--------------- Purpose of,Well Agreement- individual ad �;t`f f The undersigned agrees to'install the�aforedescribed individual well in accordance with the provisions of The Town-of Barnstable Board of Health I;rirv`ate.Well Protection,'Regulation `- The undersigned further agrees not to ,,place the well in perYtion until a Gerd icate&.oCdfnpliance,has been issued-by the Board of Health. date 'p eplication Appro� &B d / ate Application Disapproved for{the following reasons:------.---- --------------------- date----- 4 „..-... pV Permit No. Issued--- -- -� ` — --- f r date BOARD OF HEALTH f TOWN OF BARNSTABLE C ertif irate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), of Repaired ( ) by----------------- - �',�c_l wit H&I//- - -- — ——----------------------------------------------------- ----- Installer v i!U G s Pi,_ _- 8-`!------- -- - ----- ------ --- ---- -- --- ------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit NaYY--= -l` THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------- ---- -- —-- — — -- ,Inspector--- - —------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Yell Con5tructionPermit No. /`^--�_. Fee -- --- Permission is hereby granted-� -�- -- -- --- —- to Construct ( K Alter ( ), or Repair ( ) an Individual Well at: No. / ------------------------------------------------------------------------------------ �——_—�— Street as shown on the application for a Well Construction Permit No. Yy' "- ---- Dated ' `� ----- —-- — - ---- — - - - ----- --------------------- - ��,,,, Board of Health DATE---7 --—----- - — - r „ a ENVIROTECH LABORATORIES, INC. j a MA Cert. No.: M-MA 063 449 Rte. 130 . Sandwich,MA 02563 (508)888-6460 0 1-800-339-6460 FAX(508)888-6446 CLIENT: Jim Crocker LOCATION: 84 Indian Spring ADDRESS: P.O. Box 496 W. Barnstable, MA Osterville, MA 02655 SAMPLE DATE: 4-4-95 COLLECTED BY: D. Pennini/ D.A. Scannell DATE RECEIVED: 4-4-95 TIPS: 1:30PM LAB I.D. NO. : E4-47 JOB TYPE: New Well SAMPLE I.D.NO. DAS 84 WELL SPECS.: 45, RESULTS OF ANALYSIS: Parameters Units Recommended Limit Result Coliform bacteria/100m1 (P4F Method) 0 0 p1i pIi units 6.0-8.5 5.32 Conductance umhos/cm 500 78 Sodium mg/L 28.0 8.1 Nitrate-N mg/L 10.0 0.44 Iron mg/L 0.3 0.08 Manganese mg/L 0.05 0.020 Volatile Organics ug/L See enclosed report. EPA method 524 None detected. COMENTS: Low pIi indicates high corrosive characteristics. Yes No WATER IS SUITABLE FOR DRINKING PURPOSES rOR PARAMETERS TEST D. XXX Date Ron ld J. Oari Laboratory Director IT = Less Than a� p LAPUCK ~' LABORATORIES, INC. 50 Hunt Street CHEMICAL ANALYSIS Watertown,MA 02172 BACTERIOLOGY (617)923-0300 WATER ANALYSIS FOOD ANALYSIS SPECIFICATION TESTING REPORT LAB. NO. 52124 April 14 , 1995 Mr. Ron Saari ENVIROTECH LABORATORIES , INC . 449 Route 130 Sandwich, MA 02563 P.O. 14020 Sample I .D. Crocker Samples Received: - April 10 , 1995 Sample Identification: One ( 1 ) VOC Vials ( in duplicate ) labeled : Indian Spring- 4/04 Test Method: E.P.A. Standard Method #524 Test Results in ppm (mg/L) E. P.A. #524 See Attached LAPUCK LABORAT'OR.JES , TNC . Gh�UMelae�•�— James Fontenarosa Laboratory Manager- Consulting & Testing Services for over 20 Years... This report is rendered upon the condition that it is not be be reproduced wholly or in part for advertising or other purposes Over our signature or in connection with our name without special permission in writing.Total liability is limited to the invoiced amount.The ir•ullI li,le,l irlir I411V 6-a:;trd sample,and'.,r applicabh:par:uuAer, LAPUCK LABORATORIES, INC. 50 Hunt Street CHEMICAL ANALYSIS Watertown,MA 02172 BACTERIOLOGY (617)923-0300 WATER ANALYSIS FOOD ANALYSIS SPECIFICATION TESTING REPORT LAB NO. 52124 Mr. Ron Saari ENVIROTECH LABORATORIES , I . Client I . D. : -Crocker/Indian Spring ---------------------------------------------------------------------- ---------------------------------------------------------------------- Volatile Organic - EPA Method #524 in ppb ( u L.). RESULT RESULT Benzene ND 1 , 2 Dichloropropane ND Bromobenzene ND 1 , 3 Dichloropropane ND Bromochloromethane ND 2 , 2-Dichloropropane ND Bromodichloromethane ND 1 , 1-Dichloroproperie ND Bromoform ND cis-1 , 3-Dichloropropene ND Bromomethane ND trans-1 , 3-Dichloropr•opene NI) n-Butyl Benzene ND Ethylbenzene ND Sec-Butyl Benzene ND Hexachlorobutadiene ND Tert-Butyl Benzene ND Isopropyl.benzene ND Carbon Tetrachloride ND p-Isopropylt.oluerie ND Chlorobenzene ND Methyl. Chloride ND Chloroethane ND Naphthalene NI) Chloroform ND n Propylbenzene ND Chloromethane ND Styrene ND 2-Chlorotoluene ND 1 , 1 , 1 , 2-tetr•achl.o.r•oet.hai-ie N1) 4-Chlorotoluene ND 1 , 1. , 2 , 2-tetrachlor•oet.lrarte. NI) 1 , 2-dibromo-3-chloropropane ND Tetrachl.oroethene Nli D ibromomethane ND Toluene ill) 1 , 2-Dichlorobenzene ND 1 , 2 , 3-Trichlor. obenzene ND 1 , 3-Dichlorobenzene ND 1 , 2 , 4-Trichloroberizene ND 1 , 4-Dichlorobenzene ND 1 , 1. , 1. Trichloroethane till 2-Chlorotoluene ND 1 , 1 , 2 Trichloroethane ND 4-Chlorotoluene ND Trichlorofluoromethane ND Dibromochloromethane ND Trichloroethene ND 1 , 2 Dibromoethane ( EDB) ND 1 , 2 , 3-Trichloropropane.. ND Dichlorodifluoromethane ND' 1 , 2 , 4-Trimethylbenzene ND 1 , 1 Dichloroethane ND 1 , 3 , 5-Trimethylbenzene ND 1 , 2 Dichloroethane ( EDC ) ND Vinyl Chloride ND 1 , 1 Dichloroethylene ND Total Xy.lene ND Cis 1 , 2 Dichloroethylene ND Trans 1 , 2 Dichloroethylene ND Recoveries of Internal Standards Detection Limit :-0 . 5 & Surrogates _% Analysis Date : - 04/12/95 Fluorobenzene 89 P-Bromofluorobenzene 92 1 , 2-Dichlorobenzene-d4 98 Consulting & Testing Services for over 20 Years... This report is rendered upon the condition that it is not be be reproduced wholly or in part for advertising or other purposes over our signature or in connection with our name without special pennission in writing.Total liability is limited w the invoiced amount.The d' Ii•i. 1-11.1 ,,-I. o.1. .1r,! ui.!.-.r.'n'-,li. ihl nu ni,.. _'_-1 S 1 4 1_ t. i P91*vrlsga 00 ♦ L .-,1 r -1 1 ♦ \ I I I.. a ..._..__ _ _.J�..�K__•.__"!'V! ...,: .. .. j. /-{ - ._ - - ... •• i 1 r - a -ti 1 L w :jt4 O A�Id I1.. t r ' 4# Lo —, _.- WFLL CREA'CEcb • I `µ j L1_ f \ \��a� 1 � // / // \ LoT•8 `I'Co�O`>k D �F� ��-i !�I�_; ±-_.u-:_�. Li_�_u>i.- � � ' i , i t ( t t t I r + i s i , !=Y it 'LI p ! +�i .... !/_25i ' ' 1 1 t� -F N�� t — — — — _ -- Fe z . �a__- -� - - - - - NZ, ?-` 4-I-} i 1 1 -`�G-otelG I r f - I wl -- -- _ : , r ii^ 15 Ac /� i _ I rsg-W� • ors _ 1 � 1 t i ' ale ((� ��R�►TG� _� � MIN�ItNCN % �� �11"fE• �� Ms+v i, . R`�n Woo Mp HI T. 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