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HomeMy WebLinkAbout0140 GREAT MARSH ROAD - Health 140 Great Marsh Road West Barnstable r - • A — 089 005007 , 0 c; v 4 Commonwealth of Massachusetts �$9_005 DO:�- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name 01 information is West Barnstable Ma 02668 5-9-18 required for every page. City/Town State Zip Code Date of Inspection d-15 6 40 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:out When fillip out forms A. General Information j' 01 f on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey 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-C653 S113747 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 cased 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 5-9-18 Inspector's Signature Date The system inspector shall submit a copy.of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 l� A Commonwealth of Massachusetts w0ffimW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name information is required for every west Barnstable Ma 02668 5-9-18 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: ® I have not found any information which indicates that any of the failure criteria described in 31C CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. t Comments: The system was in working order at time of inspection. B) System Conditionally Passes: ❑ One or-more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the t:ox 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name information is recuired for every West Barnstable Ma 02668 5-9-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will 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 Great Marsh Road Property Address John Lawrence Owner Owner's Name information is required for every West Barnstable Ma 02668 5-9-18 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 El ® 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 day flow than 1/2t5ins•311.3 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 Great Marsh Road _ Property Address John Lawrence Owner Owner's Name information is required for every West Barnstable Ma 02668 5-9-18 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 asses if the well water analysis, performed Y p y d at a DEP certified p 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. ❑ IZ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments %M 140 Great Marsh,Road Property Address John Lawrence Owner Owner's Name requir a-ifo is West Barnstable Ma 02668 5-9-18 required for every page. Citylfown 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? ® 1 ❑ 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 breakout? ® ❑ 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 15.203 (for example: 110 gpd x#of bedrooms): . 440/GPD t5ins-3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts qi Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^N 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name information is required for every West Barnstable Ma 02668 5-9-18 page_ City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA 9 ( Y 9 (gpd))� Detail: "WELL WATER" Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 W Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Road Property Address -- John Lawrence Owner Owner's Name information is required for every West Barnstable Ma 02668 5-9-18 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 9-2013 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•113 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 Great Marsh Road Property Address John Lawrence Owner Owner's Name informatequired for is West Barnstable Ma 02668 5-9-18 required for every 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: 6-7-02 per COC 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: >100' from the well to the SASfeet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 8 ---- feet Material of construction: H 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 llons Dimensions: 1500ga - Sludge depth: 4 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 140 Great Marsh Road _ Property Address John Lawrence Ow-ier Owner's Name information is required for every West Barnstable Ma 02668 5-9-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance f,om top of sludge to bottom of outlet tee or baffle 32 Scum thickness 1 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 15" 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 working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete: ❑ metal ❑fiberglass El 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name requir required is West Barnstable Ma 02668 5-9-18 required for every pige. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan).- Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3:13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name information is required for every West Barnstable Ma 02668 5-9-18 page. Cityrrown 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 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 is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up.. 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.): NA * 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-2413 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name information is req.iired for every West Barnstable Ma 02668 5-9-18 pace. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (5) Cultecs 13'x33.5' ❑ 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 in working order at time of inspection with no sign of hydraulic failure. Leaching was dry when v.ewed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name information is required for every West Barnstable Ma 02668 5-9-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name information is required for every West Barnstable Ma 02668 5-9-18 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 El drawing attached separately Driveway Al.27` A2-33' A3-40' 131-21' A 52-14'6" 133-12' D C4-85' C5- 11'7' O 2 D4-102' D5-127' g 3 C 5 4 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Road Property Address John Lawrence Owner Owner's Name information is required for every West Barnstable Ma 02668 5-9-18 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: No GW @ 166" 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: Aug-14-2001 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Road Property Address r John Lawrence Owner Owner's Name information is required-or every west Barnstable Ma 02668 5-9-18 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r ENVIROTECHLABORATORIES,INC. MA CERT.NO.:M-MA 063 449 Rte.130 Sandwich, MA 02563 508(888-6460) 1-800-339-6460 f FAX(908)888-6446 CLIENT: Lou Seminara LOCATION: Map 089, Pcl. 5-7 ADDRESS: PO Box 1219 Kot 7, Great Marsh Rd. S. Dennis, MA 02660 W. Barnstable, MA COLLECTED BY. Desmond SAMPLE DATE: 7/30/2001 SAMPLE TIME: 5:OOPM WATER SAMPLE TYPE: New Well DATE RECEIVED: 7/31/2001 LAB I.D. #: 0107718 WELL SPECS.: 4"X 110' RESULTS OF ANALYSIS: Parameters Units Recommended Results Method Date Analyzed Limits Coliform bacteria /100ml 0 0 9222 B 7/31/2001 pH pH units 6.5-8.5 6.50 4500 H+ 7/31/2001 Conductance umhos/cm 500 121 120.1 7/31/2001 Nitrate-N mg/L 10.0 0.609 300.0 7/31/2001 Nitrite-N mg/L 1.00 < 0.003 300.0 7/31/2001 Sodium mg/L 28.0 14.6 200.7 8/1/2001 Iron mg/L 0.3 0.1 200.7 8/1/2001 Manganese mg/L 0.05 0.136 200.7 8/1/2001 Volatile Organics ug/L See report. None Detected. EPA 524.2 8/11/2001 COMMENTS: Manganese is not a health hazard, but may cause aesthetic problems. WATER MEETS EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. <=less than Dak L3 l� >=greater than nald J. S ari TNTC=too numerous to count L boratory Dir ctor TOWN OF BARNSTABLE ✓ LOCATION 6�T 7 (59115AT /"l496k- SEWAGE # 2661 VILLAGE A). 8[92Ns7'/�6� �ASSESSOR'S MAP& LOT e s' INSTALLER'S NAME&PHONE NO. M, (2 • I�� ��'�f� SEPTIC TANK CAPACITY /-"d D 6144- / \\ i LEACHING FACILITY: (type)-M6A)C4 /C#G (size) /3*'X 3 3.s L NO.OF BEDROOMS n BUILDER OR OWNER ;5 EAR Afed l 4-pj-sn �1eP PERMrrDATE: S -30 -O( COMPLIANCE DATE: - -pZ 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 Facility(If any wetlands exist within 300 feet of leaching facility) Feet Fumished by Z - 33 ' Z ' 1416 Z. 8t�' i t i S. i 1yo TOWN OF BARNSTABLE LOCATION 67 7 Q>Y SEWAGE # fir 1 VILLAGE Gc�e �F}f�N3?'��L+^� nASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /"(. 1 VI. � 'lrf✓f--� SEPTIC TANK CAPACITY 15-60 6�L LEACHING FACILITY: (type) ca CO (size) /3,x 3�. NO. OF BEDROOMS BUILDER OR OWNER 6 EM[1-)&ZA PERMITDATE: �/ 3 0 `D COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A.)& Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by `��'yg,A Rif}T A4r-i2,5 A � �}- ! - zqI = oil U-) r 6 --3 �= IZ'1 r S � No. l .. Fps... 1. . THE COMMONWEALTH OF MASSACHUSETTS `G ✓� BOAR® OF HEALTH (/ TOWN OF BARNSTABLE Appliration for Di-niputi al WorkB Tvastrnrtinn rumit Application is hereby made for a Permit to Construct (41 or Repair ( ) an Individual Sewage Disposal System at: I qD G.�t..'..?_...... -u -�.Ale ---------------------BAP---._ .?... L a .... •--- --••-- ------. ------- -- ._ jInstalleIMF Address Type of Building `l'" j.� re Size Lot._ '.f 3�-�---Sq. feet U Dwelling— No. of Bedrooms.-.----.�-------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons-__-_---_---_---.-----_-.- Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------------------------------ ---------------------------------------- DesignW Flow................1Z .................gallons per person per day. Total daily flow..... e . _,1-- -- g P P P Y• Y .7-•--- - -- --- -----------------gallons. WSeptic Tank—Liquid capaciV gallons length-//'_-.-_-_ Width---�_P----- Diameter................ Depth...4���. x Disposal Trench—No. �.............. Width_f _._.._.___ Total Length.3.7.-1....... Total leaching area___.44 7. Seepage Pit No...................... Diameter.................... Depth below inlet-------------------- Total leaching area..................sq. ft. Z Other Distribution box ( �� Dosing tank ( ) Percolation Test Results Performed b ��....Q._�� _GSA' Date-_- Test Pit No. I.....5.....minutes per inch Depth of Test Pit.1 y__------------ Depth to ground water_AJ%..C_J_�__ (� Test Pit No. 2....... per inch Depth of Test ------ Depth to ground water......... ............. } -------------------------------------------------- O Description of Soil .-- 7_Lr .-�.J U •--•-- w VNature 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 TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compli nc has been ' sued by t e board of health. Signed --- ----- --- ' - .... _..:. Application.Approved By O Dace Application.Disapproved for the following rear s . ............... ........ . Permit No. ---------- -------- -- - ---------- e Issued - -oar, � .. 'r Fimic THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH TOWN OF BARNSTABLE Applirattnn for Di-lip Sul 10urk,g Tott9trnrttun Vantit Application is hereby made for a Permit to Construct (4-f or Repair ( ) an Individual Sewage Disposal System at• Ho 7 -71y �, t�J . <'ia �...�...tr�s'�.c�' 9 ... ~ �I� ,,A,J Pcat l drrs "l IZ- or yLot No a t ......._ .............................. .t aw e ......•....... t Ox`ncr•". ��= � _3.!G.ddrl l l! •S I............................ ._._..__... � (Installer 1,', Address U Type of Building �� t..�f' r� Size Lot_.__ .agp ...S feet DwellingNo. of Bedrooms--------------------------------------------Expansion Attic g q'( ) a Other—Type Typer of Building --------------------------•- No. of persons------------ ..-----__(-_.-)Showers (Crajba eCafeter a ( ) 04 Other fixtures .. _-------- W Design Flow---------------- ................gallons per person per day. Total daily flow-------`a� 4�--_--_.-----_-_-,-..__-gallons. WSeptic Tank—Liquid capacity<$;�t!;�galIons Length_�L_.___..._ Width---- _(----- Diameter................ Depth_._ ./_ .. . x Disposal Trench— No. .................... Width_��.-_.--_-- Total Length.33e.. ....`-_ Total leaching area___, q f`i Seepage Pit No--------- ----------- Diameter._--. ----------.-- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( —)—'`- Dosing tank ( ) . '—' Percolation Test Results Performed b - .... Date___s- '� .= ` _^- --.. a Test Pit No. 1-_-.--.tea..-__-minutes per inch Depth of Test Pit-/`�.�_- ...... Depth to ground water. 44 Test Pit No. 2.....C...-minutes per inch Depth of Test Pit��-�._�_. Depth to ground water......... P4 - ------------------- -- D Description of Soil--- V .........................................••-•••-•--•-••-•••------••-•-•••••--------•••---•-•-•••--•--•---••--------••------------•••-----••-------••-----•---•-------••--••-•-••-.....---••-•-•--•-••••-. W x -------------------------------------------- •-------------------------------------------------------......_...._. U 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the `/. �Y-�-a and of health. A Y P p , C. M, system in operation until a Certificate of Compliance has been i sued b the board Signed �. _ r ------- :.�.-------- - '' ------------- A 'cation.Approved B ---------- I t Application Disapproved for the following reasonr;f j ,--_----. -----.... ----------------- -...........------ ... --...... t- .......---------------......-------------------------- r �} 1 r Date Permit No. t / -�• ......) IssuedXj[....Y -... --� ----....... t y. ---_ l ------(.................... Datrt THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f TOWN OF BARNSTABLE �Lertifi ate of Comp inure THIS IS TO CERTIFY, T t the Individual Sewage Disposal System constructed ( �Q) or Repaired ( ) by .---�lU;.._..--..(� 't � � ------------------ ---..----------------------------------- _- --------------------------------------- ---------- h.,tairt" at ..--._---------------------_--------------------------------------------------------------- ------------------------------- --_-----------------------'-------....--------.-------.._...._..---------------------...--.. has been installed in accordance with the provisions of TITLIp? f Th'e State nvironmental Code as described in the application for Disposal Works Construction Permit No. -.- 1-� -. dated -------------------------.-. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT'"BE CONSTRUED, AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------ ..... !.` - --------------- Inspector .--. or 1A-✓11..- 'y, ^.,_ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r,)" M yl TOWN OF BARNSTABLE No . �:.....••..... �f / > J f `°`'+. FEE..._..--•--•............ �i��rn,��t1 nrk� �un�tr�tilan erntt 4 Permission is hereby granted_....__- ''` f. ....�V_ d"- : { � �._f_ --'-— . J w to Constru�,(��-or,,R�pa .-( ) ,an, Individual,S�age Disposal gSystem r t t �' at No...... .............. •- -, I t �1 , r 1 r . / led 1, r ' t t ...Street �'1f--.. .` � � r led ............................................ as shown on the application!or Disposal Works Construction Permit. No� ---- Dated........................................... .I --•••---•••-••. ► C� ; Board ofi'Health l 1 / . _J l! r, i ! DATE -• ••. (- ..............................FORM 36508 HOBBS a!t WARREN,INC..PUBLISHERS BOARD OF HEALTH TOWN OF BARNSTABLE 1LP AppCicat ion-forVeil Congtruct ion Permit Application is hereby made for a permit to Construct ( &4-,'Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Par /c�I _/QD —�o�/ — J . O er Address lz2 S/h®�4 _�Uz/ ---------- ------------------- Installer Driller Address era6 61) Type of Building � Dwelling-------------------------------------------------- Other - Type of Building ----- No. of Persons----------------_----- —__—__--_____ Type of Well /0 a— U -=-���-- C acitQ=!`1 YP Capacity —— Purpose of Well--- 6s 77 =------------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate Compliance has been issued by the Board of Health. Signed ---- 1A ��,? --- date Application Approved By— ------—— — �— date Application Disapproved for the following reasons:-----------------------______—________—__—_--_—_ ------ — - --- ---------------------------------- �� date — Permit No.- 1 —0S _— Issued--------- � date _ BOARD OF HEALTH TOWN OF BARNSTABLE Certif cAte ®f Compliance THI S TO CERTIFY Th t the Individual Well Constructed Altered ( �, e ( ), or Repaired ( ) by��%Yll/,Yi��� �------------- ----- 1 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 No.iN )-(2'5-Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- Inspector-------— --- -- No--------------------� Fee -------------- BOARD OF HEALTH TOWN. .' OF BARNSTABLE ��. licatiori-for elruction 1 ��� ,�o ou hermit Application is hereby made for a permit to Construct ( .�'Alter ( ), or Repair ( )an individual Well at: ; T 7 A_7 _�f 0 0 3-- UQ7 ---- ... ------ - ---- ------ 3 tiocatwn ""Ad`dress• ,C Q Assessors Map and Parcel /47G117ii/jCr/ _ s.t�'YYJi/7Cci7 � C. / © —- Ow er - Address Installer — Driller Address Type of,Building Dwelling -- ---- - -- = --- - Other -.Type of//Building-=------------------ No. of Type of Well Purpose of Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable,Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the-Board of Health. Signed —----- ---- - -2�-�-- date f Application Approved By — —_—__—_________— — a s o date Application Disapproved for the following reasons: date ---- Permit No. _W " ZW I �S ----- Issued--- =- <9 30 ---— ---- date i-sise.e:4.,:eases..e,.�,e.r�.t..n:!ea*eii!:::�'ea+ssc -:�:.:ea�sa+ree�aamtoirew:.waacraeisrwas«o3e�r:wa�saw:�re�5oaw,aseaw.--�aarr�wa+ssaeae..aaearmaetsu�•c:a� earaer.9.o:e.erei�ae.eotc BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THI$_.IS TO CERTIFY, That the Individual Well Constructed ( ✓l, Altered ( ), or Repaired ( ) �CS t7��riv . Y✓E�ti:__�/�.PiGG ire Z-� _ -- --- - -- by . — �-------- -- - ------- --------- /�, / Installer — at__!!�_ - has been installed in accordance with the provisions of the Town of Barnstable Board of Health w-IM)-0S /s�o�Private Well Protection a Regulation as described in.the application for Well Construction Permit No. -----------____Dated----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- __ Inspector �aa?iili ir�a�YMiii,ir!)TfOiCifrA6iJi4ebriir��raf,.�ti�lY'�fb!•&'Sd"s4lblSie�4lifafiii6@iRi'4iiigi'?ati0i"fi'S49ilitSMO'issGR¢siT6�dppay�gE9646A!GiY�tifeiAi3,iRA,+tieili4SE►RiBiSi°'dP0'^tTi3YTE:59:'*� BOARD OF HEALTH TOWN OF BARNSTABLE Vell Con5tructionpermit No. -----z ^ W Fee-Z- // Permission _ ss><on is hereby granted �� — _-�—_— --------- to Ck Constvs o. ruct ( f s Alter ( ), or Repair ( ) an Indivi ual Well at: ,// p- ------------------- --------------------------- Street as shown on the application for a Well Construction Permit ff W- ZOO ) —OS � �/U 1 No. - -- _ Dated-- _! DATE W Z ��� Board of Health f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments M 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name requir required is West Barnstable Ma. 02668 8-14-14 required for every 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: A. General Information When filling the out (/ forms on the U computer,use 1. Inspector: only the tab key to move ycur Matthew F. Gilfoy cursor-do not Name of Inspector use the retjrn key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 �Q11 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: C-7 , ® Passes ❑ Conditionally Passes ❑ Fans ❑ Needs Further Evaluation by the Local Approving Authority `s �> a 7_ 8-15-14 =a InspiciK i ure Date K; Th ystem inspector sha I submit a copy of this inspection report to the Approving.Authority(Board ' of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ***`This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Insp t F rm:Subsurface Sewage Disposal System•Page 1 of 17 r. Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is West Barnstable Ma. 02668 8-14-14 required for every 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: ® 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•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 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every page. CityTrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required forWest Barnstable Ma. 02668 8-14-14 every page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion.of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 •X, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every page. Citylrown 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 t 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 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ,\, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °° 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is West Barnstable Ma. 02668 8-14-14 required for every page City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes N 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: NA(well) Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.' 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 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/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every 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: 2002 (C.O.C.) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'4"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.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): 1,8„ Depth below grade: 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: 1500 gal. Sludge depth: 3" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne.Gorman & Mary Gorman Owner Owner's Name information is "required for West Barnstable Ma. 02668 8-14-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 33 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1 I 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 15" 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.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back up.Liquid level equal with 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•3/13 Title 5 Official Inspection Fomm:,Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts JD Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to.outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of.current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every 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 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 appears to in working order no sign of deteration, or 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.): * 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 JD Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne Gorman'& Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 5 cultecs ® leaching chambers number. (1TX335) ❑ 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 appears to in working order no sign of hydraulic failure. Leaching vented (vent pipe in woods) - 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 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy.(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth:&Massachuse#s Title 5 Official Inspection Form Subsurface Sewage Dis Deal S stem Form - 9 p Not for Voluntary As Y. ry Assessments � 140_Great Marsh Rd. PropertyAddress Anne Gorman &Mary Gorman Owner Owners Name information is. required for West Barnstable Ma. 02668 8-14-14 every page. CitY/Town State Zip Code Date.of Inspection D::Systern 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 'Nell Q drawing attached separately pEc � a c 5 `t R �2 3 C5 t A3 1lit b%I �3 -11t t5ins•3/13 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts ID Title 5 official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every page. CitylTown 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: no GW 166" feet i 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: Aug-14-2001Date ❑ 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: Plan on File at 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= r Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Great Marsh Rd. Property Address Anne Gorman & Mary Gorman Owner Owner's Name information is required for West Barnstable Ma. 02668 8-14-14 every 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 i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION 6�T 7 412,5/- Q> SEWAGE # 2061 - VILLAGE • I36�}2N 'fI Qvc-�' nASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)7I2, i �^� t�CT�-G�) (size) 13 t'X 3�- NO. OF BEDROOMS 4 /} BUILDER OR OWNER 66U411JqeA PERMITDATE: 6 -30 -01 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 Facility (If any wetlands exist within.300 feet of leaching facility) Feet Furnished by G R 5A AAA-/21S if Rp- Z/? Z � 3,3' /416 D L Z -/ 1-1 ) r S Al TEST HOLE LOG DATE: AUGUST 14, 2001 P-10046 N J SOIL EVALUATOR: X. O'LOUGHLIN, CSE ��// "/ IN• WITNESS: G. HARRINGTON, BHD PERC RATE: 5 MIN./IN. t4q Stio i y / 40 Z o" •D O" a lLt all r3sa :.,.. A - LOAIfY SAND 10YR4/1 16^ / Bw - LOAMY SAND Bw = LOAMY SAM loxes/e 10YRs/e :C - NEDIt1N-FINE Cl - lO )rm— �r SNm F313E SAID 1° C •�'� 2.5Y7/4 2.SY7/4 144" 166" 1.O WATER ENCOUNTERED DESIGN DATA f DAILY FLOW: (4) BDRMS. x 110 GPD = 440, GPD ✓y SEPTIC TANK: 440 GPD x 200% = 880 GPD SJ , USE: 1500 GALLON PRECAST SEPTIC TANK Q LEACHING FACILITY: USE: (3) 5' x 8.5' 500 GAL. PRECAST DRYWELLS LINED w/4' OF DOUBLE WASHED STONE' OP v�. CAPACITY: f SIDEWALL: 93 x 2 x 0.74 = 137.6 BOTTOM: 13 x 33.5 x 0.74 = 322.3` f + TOTAL: 459.9 GPD 4 ' t ♦ f o - QRCA7 MARM �- � � exaC� °two, �t 6" -51 r ° z LOCATION MAP NOTES: 1 1. ALL PIPE TO BE 4" DIA. SCH 40 PVC. ) S A�A 2. PIPE TO BE LAID LEVEL FOR 2.' OUT OF DISTRIBUTION BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6" OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE US% OF A GARBAGE DISPOSAL. 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6" LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2" LAYER Or 3/6" PEASTONE OVER DOUBLE IMSHED STONE ALL AROUND TOP OF FOUND. T!E @ BLEV. eo.00 Bs�r, yszo �, $o,oa 6,► .�o SEPTIC SYSTEM PROFILE IA A A A GENERAL NOTES, BS•�t7 kAO�Z SITE ^' SEWAGE PLAN �p�1,� �; �� 1. CONTRACTOR TO BE RESPONSISLB FOR THE 'IMMIOii P FOR �1'EV NW 9F ALL VTILITISH, A 4 1►80 , �� �. TO ANY EXaVASION 09 CONSTUXTION LOT 7 GREAT MARSH RD. , WEST BARNSTABLE, MA ASSESSORS MAP 89 PARCEL 5-7 1'J 2. SEPTIC SYSTEM TO B8 INSTALLED IN COMPLIANCE filfiH t 310 CHR 15. 00: TITLE V.' + PREPARED FOR 3. THIS PLAN IS NOT TO 88 USED i�OR PROPERTY LINE f DETERMINATION. %'-} SEMINARA CONST . CORP . O02A,Olt 4. ALL DISTURBED AREAS TO LOANED AND SSED=D. DATE • AUGUST 27 , 2001 SCALE : 1" = 40' 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FM ANY ; REQUIRED INSPECTIONS. �P`i1 OF MAC 6. REMOVE ANY IHPHRVIOUS MATERIAL FOR A 5' RADIUS ; ci DANIR E. yG AROUND THE LEACHING AREA AND REPLACE WITH CLSAX WELLER 6 ASSOCIATES BRAMAN MEDIUM sm. o CIVIL y 164 5 FALMOUTH RD. SUITE 4 C P.O. BOX 41 u No.32686C y 3 CENTERVILLE, MA 02632 Pt APPROVED BY: TEL: (508) 775-0735 FAX: (508) 775-0754 �fssrpa�tE��' — — �• o.o l 1� "A'A ISO J 70 ....... -W- -1 WAR x1n; -T�- 7-7' 7-7 ------- F, MEW ve -47--7 t-77- sit A P —7-7 v Opp symiggy MAW ma :111 --------- I - - -6, ":�77 tj 00, q.0a,4, Sul ' i Alp R 71\ 10 Y- .7 7 i��- ""Wag 0jQ Spy ,MAE A toy," AN topic M Q�j vqj"" VT IL 7i 3. its, �Xmu ,A, :� '; ' �:' �1.I � �' : ��' ,,, ''9. vi, vivo WA, ...... r- AM 7110 EMMA :,f -gym 9 10 0 hoot e ,H " MOWS, a RM, L Zc .jg cog VMS& K -�7�7 7-1 3", -: 77 e, -AU V� mass i A XIAM ANN last 0444 , It ON wit 14 mg moon AIR all i".'-'' cm 'V, D two WE A�', 7,;' mg All Wo lilt 0;- VP M 06 00 .6.0 R, .64........... Way! IS lus 1 4%=mom I m ."T K