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'Values: Land 000100800 'BWdA"' 000281600 ,i=xfira Features. 0000000000�
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
z
MAR - ill
PARCEL , 3 O
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 224 High Street,West Barnstable,MA
Owner's Name: James Robbins Jr. FREC7EIVEDOwner's Address: 224 High Street,.West Barnstable,MA
Date ofInsMay 23,2003 Name of Inspector: REED C.ELLIS
Company Name: ELLIS BROTHERS CONST.CO.
Mailing Address: 23 ENTERPRISE ROAD, TOWN OF BAREPT
HEALTH DEPT..
P.O.BOX 59,YARMOUTH PORT,MA 02675
Telephone Number: 508 362-6237
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000. .he ems.I am a DEP
� system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ands,
Inspector's Signature:
Date: (73
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 now 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 sen
authority. t to the buyer,if applicable,and the approving
1
Notes and Comments ''� �� �� v 1,4, - ,U"
IJ
This report only describes conditions at the time of inspection
time.This inspection does not address how the system will o�in�e der the conditions of use at that
conditions of use. Pe future under the same or different
Wage 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins Jr.
Date of Inspection:May 23,2003
Inspection Summary: Check A,B,CM or E/ALWAYS com fete all of Section D
A. System Passes:
N I have not found any information which indicat that any of the failure criteria described in 310 CMR
15.363 or in 310 CMR 15.304 exist.Any failure criteri not evaluated are indicated below.
Comments:
B. System Conditionally Passes: /v
One or more system components as described In the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacem nt or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*i ir the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration 3r tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank i s approved by the Board of Health.
*A metal septic tank will pass inspection if it is structu ally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is avai le.
ND explain:
Observation of sewage backup or break out or I tigh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or unevet distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)an replaced
obstruction is reir oved
distribution box" leveled or replaced
ND explain:
'Me system required pumping more than 4 tfin s a year due to broken or obstructed pipes).The system will
pass inspection if(with approval of the Board of Heal ):
broken pipe(s)are -eplaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins JR.
Date of Inspection:May 23,2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the B d 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 ac mrdance with 310 CMR 15 303(l)(b)that the
system is not functioning in a manner which will protect ublic 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 veget led wetland or a salt marsh
2. System will fail unless the Board of Health(and Public V rater Supplier,if any)determines that the
system is functioning in a manner that protects the public he dth,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 m'thin a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is m'thin 50 feet of a private water supply well.
The system has aseptic tank and SAS and the SAS is 1 s than 100 feet but 50 feet or more from a;
private water supply well".Method used to determine dista iice { `
"This system passes if the well water analysis,performed a DEP certified laboratory,for coliform �A:
bacteria and volatile organic compounds indicates that the 11 is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is eqx al to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be ittached to this form.
3. Other:
3
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins Jr.
Date of Inspection:May 23,2003
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or`ono"to each of the following for s0 inspections:
Y N/Ba
ckup 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
I ool
iquid depth in cesspool is less than 6"below invert or available volume is less than'/�day flow
R uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ y portion of the SAS,cesspool or privy is below high ground water elevation.
wsurfy portion of cesspool or privy is within 100 feet of a water supply or tributary to a surface
ace
ter supply.
y portion of a cesspool or privy is within a Zone 1 of a public well.
dry portion of a cesspool or privy is within 50 feet of a private water supply well.
�l Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are trifg�geered.A�py of the analysis must be attached to this form.]
YesINO '1�ie system fails I have determined that one or more f( ) sy o e o the above failure criteria exist as
described in 310 CUR 15.303,therefore the system fails.The system owner should contact the Brd of
Health to determine what will be necessary to ect the failure. F
E. Large Systems:
To be considered a large system the system must rve a facility with a design flow of 10,000 gpd to 15,0Q0
1'pd.
You must indicate either"yes"or"no"to eachof the ofowing:
(The following criteria apply to large systems in ad di on to the criteria above)
yes no
— the system is within 400 feet of a surface dz inking water supply
the system is within 200 feet of a tributary I D 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 Secti E the system is considered a significant threw or
"Yes"in Section D above the large system has failed.The owner or Operator of an lace t' answered
significant threat under Section E or failed under ion D shall upgrade the y g da considered a
15.304.The �� ��m accordance with 310 CMR
system owner should contact the appr ate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins Jr.
Date of Inspection:May 23,2003
Check if the followin have been done.You must indicate` es"or"no"as to each of the following:
g �
Y�No
_ mping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks`?
_ as 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 ?
V _ 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,jacluding the SAS,located on site`?
_ Were the septic tank manholes uncovered,opened, P
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.`
Y no
_ Existing information.For example,a plan at the Board of Health.
V _
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
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Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins Jr.
Date of Inspection:May 24,2003
FLOW CONDITIONS
RESIDENTIAL 2
Number of bedrooms(design): Number of bedrooms(actual): —
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 23
Number of current residents:_;)-_
Does residence have a garbage grinder(yes or no): �
Is laundry on a separate sewage system(ye r no)ik X1 [if yes separate inspection required]
Laundry system inspected(yes o o):*,'
Seasonal use:(yes or no):
Water meter readings,if avail ble(last 2 years usage(gpd))
Sump pump(yes or no):
Last date of occupancy:
COMMERCIALANDUSTRIAL / 4
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system (yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: allons--How w s quantit pumped etermined? (� 4?,
Reason for pumping: LZ�v l � ►�W
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 currant operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age o comp ts,date installed(if own)and source of inform ' n:
Were sewage odors detected when arriving at the site(yes or no):/v" r I-S$U eA (.—�2 '-
6 1 ,,ajvw �c5
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins Jr.
Date of Inspection: May 23,2003
BUILDING SEWER(locate on site plan)
iDepth below grade: a-1 ��..a,�� � U 11�� �E%��
Materials of construction:_cast iron _4V 0 PVC there 1 ' .
''
Distance from private water supply well or suction line: ��it/SJacU p`a
Comments.(,an condit' of joints,ven " ,evidence of leakage,a c. .
SEPTIC TANK: locate on site plan)
In,� op
Depth below grade: 1►�6'�J (9 4 OV� I
Material of construction:Vconcrete metal_fiberglass_polyethylene
_other(explain)
10 If tank is metal list age:____ Is age confirmed by a Certificate of Compliance(yes or no):
certificate) _(attach a copy of
'
Dimensions: L D-y '
Sludge depth: �o' �8
Distance from top of sludge to bottom of�.outfletttee or baffle:
Scum thickness: I/
Distance from top of scum to top of outlet tee or baffle: IZ9 y
Distance from bottom of scum to bottom of outlet ee or baffle: �1
How were dimensions determined:
Comments(on pumping recommen ons,inlet and outlet tee or Me co itio ctural integrity,liquid levels
� as related to outlet inviprt,evidence f leakage,
GREASE TRAP: (locate on site plan)
Depth below grade:
Material of construction:____concrete metal fi glass_polyethylene_other
(explain): —
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or ba
Distance from bottom of scum to bottom of outlet t or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins Jr.
Date of Inspection: May 23,2003
TIGHT or HOLDING TANK: (tank must b ped at time of inspection)(locate on site plan)
E
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes o•no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be open d)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and di:-b—{"n to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.)S �n � i
liiUNPIV ,` �,.1 fl •fix v,Go i
PUMP CHAMBER: (locate on site plan) 1
Pumps-in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,Condit on of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins JR
Date of Inspection: May 23,2003
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
[ape! leaching pits,number:f `
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensiow
overflow cesspool,number:
innovativetalternative system Typeiname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): ' '
5
`J. ��o C�✓�-'�.�'.� " I S .� 'f'•bf-t0�1 !-"s� a1�j�-po�14'�►�' IoA �
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) /�{- b vo:"—
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic lure,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 faili ire,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS I, r
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins Jr rr"
Date of Inspection: May 23,2003
/N
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
1 �
3
r`
10
f
Page 11 of 11
FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 224 High Street,West Barnstable,MA
Owner: James Robbins Jr.
Date of Inspection: May 23,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells i �/�
Estimated depth to ground water6 feet ``
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within ISO feet of SAS)
Necked with local Board of Health-explain;
Checked with local excavators,installers- attachdoc}� tat�on),
Accessed USGS database-explain: �'�i
� I
You must describe how you established the high ground Ater elevation:
5611
11
Page:
CERTIFICATE OF ANALYSIS
e l Barnstable County Health Laboratory
Report "Prepared For:
Report Dated: 6/10/2003
Ellis Brothers Construction Order Number: G0319886
Reid Ellis
23 Enterprise Rd.
Yarmoutport, MA 02675
Laboratory 1D#: 0319886-01 Description: Water-Drinking Water
" Sampl #: 19886 —`- __ . Sampling Location:224 Hi b Stree�WestBarnstable- --Collected 5/23/2003 `
Collected by: Reid Ellis Received 5/23/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB:IC Lab
Nitrates 0.6 mg/L 10 EPA 300.0 5/24/2003
LAB: Metals
Copper <0.1 mg/L 1.3 SM 311113 5/27/2003
Iron <0.1 mg/L 0.3 SM 311113 5/27/2003
Sodium 10 mg/L 20 SM 311113 5/27/2003
LAB: Microbiology
Total Coliform Absent P/A Absent P/A 5/23/2003
LAB:Physical Chemistry
Conductance 290 umohs/cm EPA 120.1 5/23/2003
PH 8.6 pH-units EPA 150.1 5/23/2003
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:
(Lab Director)
1,3
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph:508-375-6605
TOWN OF BARNSTABLE
'
LOCATION e2 v2 /t�l�t g SEWAGE #
VfVILLAGE ASSESSOR'S MAP & LOT
"VS�D£CIP&S �o S
/Diff,*L+1✓R'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ,5-lr,0 c /ti r,47 FC r.e--
LEACHING FACILITY: (type) (size)
NCB.OF BEDROOMS
LDER OR'OWNER
L .`L
+.
02 . a3
P-E�tMIT DATE: COh4CE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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i
ua: CERTIFICATE OF ANALYSIS Page.
.�StAHiss �' Barnstable County Health Laboratory
Report Prepared For: Report Dated: 6/20/2003
Gaylene Robbins Trust Order Number: G0320158
Daniel Griffin
224 High Street
Barnstable, MA 02668
Laboratory ID#: 0320158-01 Description: Water-Drinldng Water
Sample#: 20158 Sampling Location: 224 High Street,Barnstable Collected 6/5/2003
Collected by: Daniel Griffi 111-030 Received 6/5/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 1.3 mg/L 10 EPA 300.0 6/5/2003
LAB: Metals
Copper <0,1 mg/L 1.3 SM 311113 6/18/2003
Iron <0.1 mg/L 0.3 SM 3111E 6/18/2003
Sodium 3.6 mg/L 20 SM 3111B 6/18/2003
LAB: Microbiology
Total Coliform Absent P/A Absent 309 6/10/2003
LAB: Physical Chemistry
Conductance 268 umohs/cm EPA 120.1 6/5/2003
pH 7.2 pH-units EPA 150.1 6/5/2003
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:
Director)
C) -'a D 0/0
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
o ?. Page: 1
M CERTIFICATE OF ANALY IS
Barnstable County Health Laborator) JUN 16 2003
':rnrt;t_aS�:
Report Prepared For Report Dated: 6/10/2003 TOWN OF BARNSTABLE
HEALTH DEPT.
Ellis Brothers Construction Order Number: G0319886
Reid Ellis
23 Enterprise Rd.
Yarmoutport, MA 02675
Laboratory ED#: 0319886-01 Description: Water.-Drinking Water
Sample#: 19886 Sampling Location: 224 High Street,West Barnstable Collected 5/23/2003
Collected by: Reid Ellis Received 5/23/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 0.6 mg/L 10 EPA 300.0 5/24/2003
LAB: Metals
Copper <0.1 mg/L 1.3 SM 3111E 5/27/2003
Iron <0,1 mg/L 0.3 SM 3111B 5/27/2003
Sodium 10 mg/L 20 SM 3111B 5/27/2003
LAB Microbiology
Total Coliform Absent P/A Absent P/A 5/23/2003
LAB: Physical Chemistry
Conductance 290 umohs/cm EPA 120.1 5/23/2003
pH 8.6 pH-units EPA 150.1 5/23/2003
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:
(Lab Director)
R
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
3o0te(P
COMMONWEALTH OF MASSACHUSETTS
Z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
a
FRECEIVED/� 350 MAIN STREET N 2 6 2003
/�`e WEST YARMOUTH,MA
508-775-2800 TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 11I PAR 030
Property Address: 224 HIGH STREET
WEST BARNSTABLE,MA 02668 [RECE111cm
Owner's Name: ROBBINS,JAMES
Owner's Address: 224 HIGH STREET
WEST BARNSTABLE,MA 02668 2 2003Date of Inspection JUNE 3,2003 N sName of Inspector:(please print) JAMES D. SEARS N OF BARNSTABLE
Company Name: A& B Canco TH �[�T,
Mailing Address: 350 Main Street
West Yannouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(31.0 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails /
Inspector's Signature: Q Date: (O ` "9- y 3
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 tot he buyer,if applicable,and the approving authority.
1
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
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c
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 224 HIGH STREET
WEST BARNSTABLE, MA 02668
Owner: ROBBINS,JAMES
Date of Inspection: JUNE 3,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: ✓
I have not found any infonnation 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: N/A
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
f
Page 3 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 224 HIGH STREET
WEST BARNSTABLE,MA 02668
Owner: ROBBINS,JAMES
Date of Inspection: JUNE 3,2003
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to detennine 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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 224 HIGH STREET
WEST BARNSTABLE,MA 02668
Owner: ROBBINS,JAMES
Date of Inspection: JUNE 3,2003
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes'or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in pit is less than 6"below invert or available volume is less than 'h day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone I of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as
described in 310 CM R 15.303,therefore the system fails. The system owner should contact
the Board of Health to detennine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes'or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone 11 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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 224 HIGH STREET
WEST BARNSTABLE,MA 02668
Owner: ROBBINS,JAMES
Date of Inspectior: JUNE 3,2003
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?
✓ Fas 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)has been determined based on:
Yes No
✓ Existing infonmation. 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 unaccep-able)[310 CM 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
J
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 224 HIGH STREET
WEST BARNSTABLE,MA 02668
Owner: ROBBINS,JAMES
Date of Inspection: JUNE 3,2003
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms: 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): WELL WATER
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERC IAL/INDUS TRIAL
Type of establishment:
Design flow(based on 310 CM 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
./ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Pri vy
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)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
AROUND 1985
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 HIGH STREET
WEST BARNSTABLE, MA 02668
Owner: ROBBINS,JAMES
Date of Inspection: JUNE 3,2003
BUILDING SEWER(locate on site plan): ✓
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 6"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,500 GALLON PRE CAST
Sludge depth: 1"
Distance from top of sludge to the bottom of outlet tee or baffle: 29"
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions detennined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL.TANK AND COVERS 6"BELOW GRADE.OUTLET BAFFLE. INLET
TEE.NO SIGN OF OVERLOADING OR LEAKAGE.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
f
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 HIGH STREET
WEST BARNSTABLE,MA 02668
Owner: ROBBINS,JAMES
Date of Inspection: JUNE 3,2003
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alann level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alann and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
DISTRIBUTION BOX 16"x 16", 16"BELOW GRADE.ONE LINE IN,ONE LINE OUT. BOX IS CLEAN AND
SOLID.NO SIGN OF OVERLOADING OR SOLID CARRYOVER.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 224 HIGH STREET
WEST BARNSTABLE,MA 02668
Owner: ROBBINS,JAMES
Date of Inspection: JUNE 3,2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 1,000 GALLON PRE CAST PIT. PIT AND COVER 5"BELOW GRADE WITH 4'OF STONE
WATER AND STAIN LINE AT 35".
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 oft I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 224 HIGH STREET
WEST BARNSTABLE,MA 02668
Owner: ROBBINS,JAMES
Date of Inspection: JUNE 3..2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pernianent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
i
1
i
� o
Title 5 Inspection Form 6/15/2000 10
f
Page I I of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 HIGH STREET
WEST BARNSTABLE. MA 02668
Owner: ROBBINS,JAMES
Date of Inspection: ,TUNE 3,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 9 feet
Please indicate(check)all methods used to detenninc the high ground water elevation:
Obtained fr•am system design plans on record-If checked,date of design plan reviewed:
./ Observation 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:
HAND DUG TEST HOLE T NO WATER. TEST HOLE Y BELOW BOTTOM OF PIT.
i
3: /)/7—
Title 5 Inspection Form 6/15/2000 1 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
224 High Street, West Barnstable V -
Property Address _
Jeffrey Ward & Patricia S
Owner Owner's Name
information is 4 Hollies End, London UK NW72RY 12/9/2020
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:When filling out forms A. Inspector Information
on the computer, Miguel Chavez Jorge Mi
use only the tab 9 g
key to move your Name of Inspector
cursor-do not Speakman Excavating LLC
use the return Company Name
key.
Speak Way
Company Address
Harwich MA 02645
City/Town State Zip Code
r 508-432-5565 S114294
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector In full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
- Z
Inspectors ignature 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s 224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
Owner Owner's(dame
information is required for every 4 Hollies End, London UK NW72RY 12/9/2020
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
2) 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):
t5insp.doc-rev.7262018 Tdle 5 Official Inspection Fore:Subsurface Sewage Disposal System•Page 2 of 18
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward& Patricia S
Owner Owner's Name
information is required for every 4 Hollies End London UK NW72RY 12/9/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (coot.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward&Patricia S
Owner Owner's Name
required
is 4 Hollies End, London UK NW72RY 12/9/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
`title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward& Patricia S
Owner Owner's Name
information is 4 Hollies End, London UK NW72RY 12/9/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Mt day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
224 High Street, West Barnstable _
Property Address
Jeffrey Ward & Patricia S
Owne. Owner's Name
information is required for every 4 Hollies End, London UK NW72RY 12/9/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
Owner Owner's Name
information is required for every 4 Hollies End, London UK NW72RY 12/9/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): Unknown Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15,203(for example: 110 gpd x#of bedrooms): Unknown
Description:
No site plan design on file with the B.O.H.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Water from a well.
i Sump pump? ❑ Yes No
4 Last date of occupancy: 9/19+/
Date
t5insp.doc•rev.7l26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
p 224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
"Owner Owner's Name
Information is required for every 4 Hollies End, London UK NW72RY 12/9/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurtece Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
Owner Owner's Name
information is required for every 4 Hollies End, London UK NW72RY 12/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
House built in 1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
5'
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Building sewer in good condition, no evidence of leakage.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
Owner Owner's Name
information is required for every 4 Hollies End, London UK NW72RY 12/9/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 7
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: 1500gal
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
0"
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
14"
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 is in good condition, structurally sound, PVC tee on inlet and precast on outlet in place, liquid
level at outlet invert, there is no evidence of backup or leakage.
15insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward& Patricia S
Owner Owner's Name
information is required for every 4 Hollies End London UK NW72RY 12/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site pla
n):
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
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
@ Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
Owner Owners Name
information is required for every 4 Hollies End, London UK NW72RY 12/9/2020
page.e. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. 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.):
Dbox is in good condition,watertight, there is no solids carryover o vegetation and no evidence of
backup, 1 outlet.
t5insp.doc-rev.R26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M v 224 High Street, West Barnstable
Property Address
Jeffrey Ward &Patricia S
Owner Owner's Name
information is required for every 4 Hollies End, London UK NW72RY 12/9/2020
page. Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
Owner Owners Name
information is required for every 4 Hollies End, London UK NW72RY 12/9/2020
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 6'x6' pit, found dry with a visible stain line at 33"from the pipe invert, sidewalls are clean
and dry above it, there is no sign of hydraulic failure.
12. 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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.706/2018 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
\, Commonwealth of Massachusetts
R Title 5 Official Inspection Form
iSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
715 224 High Street, West Barnstable
Property Address
Jeffrey Ward &Patricia S
Owner Owner's Name
information is requited for every 4 Hollies End, London UK NW72RY 12/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5irsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
Owner Owner's Name
information is 4 Hollies End, London
required for every UK NW72RY 12/9/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
14. 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
wa 1�
X
!�EAR
►�3 t
t5insp.doc•rev.7/262018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,V 224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
Owner Owner's Name
information is required for every 4 Hollies End London UK NW72RY 12/9/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
53'+/- below the bottom of the leaching
Estimated depth to high ground water: 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:
Elevation at property: 60'+/-
Elevation at Bottom of leaching: 7'
Closest body of water, Mill pond: 0'+/-
Separation: 53'+/-
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massa
chusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
P 224 High Street, West Barnstable
Property Address
Jeffrey Ward & Patricia S
Owner Owner's Name
information is 4 Hollies End, London UK NW72RY 12/9/2020
required for every
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed &Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 Failure Criteria completed
and 6(Checklist) p t
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
COMMONWEALTH OF MASSACHUSETTS
I EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
" (1N[ WINTER STREET. HOSTON. MA 02108 611-292-5j0
n �(
. ,. � ,.�.•' . Friar.,,-' :•
I!
WILLWI F.WELD 350 MAIN STREET S E F 24 1998 TR to4 coxE
Governor WEST YARMOUTH,MA Secrctan
TOWN OF BARNSTABLE
ARGEO FAUL CEI_LUCCi 508-775-2800 J HEALTH DEPT. DAVI STRUNS
Lt.Govcmor "mmissioncr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART A _ 4
CERTIFICATION
MAP 111 PAR 30
PROPERTY ADDRESS: 224 HIGH STREET,WEST BARNSTABLE ADDRESS OF OWNER:
DATE OF INSPECTION: SEPTEMBER 10,1998 GLEN TRAVIS
NAME OF INSPECTOR: JAMES D.SEARS
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: DATE: SEPTEMBER 14, 1998
The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall
submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY: Check A,B, C, or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as defined in
310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS: SITE OVER ALL PASSES, INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM
AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
B SYSTEM CONDITIONALLY PASSES:
N/A One or more system comdonents as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved b the Board of Health,will
pass.
Indicate yes,no,or not determined(Y,N,or NO). Describe basis of determination in all instances. If"not determined",
explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of
a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)
years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally
unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass
inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board
of Health.
Page 1 of 10
(revised 04/25/97)
DEP on the World Wide Web:http://www.magnet.state.ma.un/d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
Property Address: 224 HIGH STREET,WEST BARNSTABLE
Owner: TRAVIS,GLEN
Date of Inspection: SEPTEMBER 10,1998
B]SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will
pass inspection if(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C]FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
NIA Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect.the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A
MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet to a surface water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a,private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for
coliform bacteria and volatile organic compounds indicates that the well is free from
pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and
nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance
(approximation not valid).
3) OTHER
(revised 04/25/97)
Page 2 of 10
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 224 HIGH STREET,WESTBARNSTABLE
Owner: TRAVIS,GLEN
Date of Inspection: SEPTEMBER 10, 1998
D]SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
N/A 1 have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303.The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed to be
acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,
ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following
conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or
mapped Zone II of a public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater
treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department
for further information.
(revised 04/25/97)
Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 224 HIGH STREET,WEST BARNSTABLE
Owner: TRAVIS,GLEN
Date of Inspection: SEPTEMBER 10,1998
Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following:
Yes No
N/A Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
has been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
X Existing information. Ex.Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)[15.302(3)(b)]
I
t
(revised 04/25/97)
Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 224 HIGH STREET,WEST BARNSTABLE
Owner: TRAVIS,GLEN
Date of Inspection: SEPTEMBER 10,1998
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): YES
Laundry connected to system(yes or no): YES
Seasonal use(yes or no) NO
Water meter readings,if available(last two(2)year usage(gpd): WELL WATER
Sump Pump(yes or no): NO
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1985 PERMIT#85-953
Sewage odors detected when arriving at the site:(yes or no) NO
(revised 04/25/97) '
Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 HIGH STREET,WEST BARNSTABLE
Owner: TRAVIS,GLEN
Date of Inspection: SEPTEMBER 10, 1998
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK:X
(Locate on site plan)
Depth below grade: 6"
Material of construction X concrete metal _ Fiberglass _ Polyethylene _ other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 1,500 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 91,
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How dimensions were determined AS BUILT&TAPE
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,
structural integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,OUTLET BAFFLE,COVERS 6"BELOW GRADE.TANK SHOULD BE PUMPED.
GREASE TRAP: N/A
(locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,
structural integrity,evidence of leakage,etc.)
(revised 04/25/97)
Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 HIGH STREET,WEST BARNSTABLE
Owner: TRAVIS,GLEN
Date of Inspection: SEPTEMBER 10, 1998
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Capacity:
Design flow: gallons/day
Alarm level: Alarm in working order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
BOX IS 16"X 16",16"BELOW GRADE,ONE LINE IN,ONE LINE OUT.BOX IS LEVEL AND SOLID.
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
(revised 04/25/97)
Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 HIGH STREET,WEST BARNSTABLE
Owner: TRAVIS,GLEN
Date of Inspection: SEPTEMBER 10, 1998
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number: 1
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number,
alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
1,000 GALLON PRE CAST PIT,PIT AND COVER 4"BELOW GRADE.S WATER IN PIT,NO HIGH WATER MARK.
CESSPOOLS: N/A
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 04/25/97)
Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 HIGH STREET,WEST BARNSTABLE
Owner: TRAVIS,GLEN S W� '
Date of Inspection: SEPTEMBER 10, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100(locate where public water supply comes into house)
F f4R
tck
s.c
SST
o:
I
(revised 04/25/97)
Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 224 HIGH STREET,WEST BARNSTABLE
Owner: TRAVIS,GLEN
Date of Inspection: SEPTEMBER 10, 1998
Depth to no groundwater 9 feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained fro Design Plans on record
X Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
NOTE:HAND DUG TEST HOLE.TEST HOLE NOTED ON PAGE 9.TEST HOLE T BELOW BOTTOM OF PIT.
(revised 04/25/97)
Page 10 of 10
TOWN OF BARNSTABLE
LOCATION 54 ///-4# S i SEWAGE #
j
VILLAGE A' ASSESSOR'S MAP & LOT
.INSTALLER'S NAME PHONE NO. 0
SEPTIC TANK CAPACITY /.3-" cot-
LEA RING FACILITY:(type) 7— (size)
NO.--OF BEDROOMS ,PRIVATE WEL OR;PUBLIC WATER
BUILDER OR OWNER Cy,F,4.,v `:z"- yl S
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
6 UA
C�
w
*r
f,
0
` ,1.0 CATION / SEWA- G E PERMIT' N0.
I VILLAGE
p 1NSTA LER'S- NAME & ADDRESS
t,CJ I'L D E R OR ONIM R
\J
DA-T E PERMIT ISSUED
9 � ► 2Q5
D`&TE COWIPLIANCE: ISSUED
`k
i
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
_.------_ O.hd1N..OF......... . ...At. .N_.S.TA.1 4-. --•--..._._...
C ApplirFatilan for Uhipati al Work.5 Tnnu#rnrtion ramit
Application is hereby made for a Permit to Construct (G�_or Repair ( ) an Individual Sewage Disposal
System at:
... . --•---.
Location-Address
.13 or Lot No. ®z.
A�� ._.. •M �I.EL E -��.0, ®X_.4ZAC .V_�?.1:T.._M .. .:.:......C�.
Owner Address
W ...................... ....•--•-•-----••---------.............................-•----------........................._.....
a Installer Address '
W
;Type of Building Size;Lot_. rO ----Sq. feet
Dwelling—No. of Bedrooms-_.....................................Expansion Attic (No) {" Garbage Grinder
Other—Type T e of Building K _.�_....._..... No. of persons............................ Showers Cafeteria
a YP g P ( ) — ( ) i
Other fixtures -----------------------------•----
Design Flow.................� ...................gallons per person per day. Total daily flow__._.._..__3.3Ad.................gallons.
WW a I .. ixl1� De th.. I +�
WSeptic Tank—Liquid cak�aarcit 15!*gallons Length.®_-6.__ Width...��..". .... Diameter_ p E5 1 .
Disposal Trench—No. ..!�J f ........ Width.................... Total Length______......___.... Total leaching area ----_..__..__sq. ft.
Seepage Pit No.......I------------ Diameter--------1 4....... Depth below inlet..... Total leaching area....._�...sq. ft.
Z Cther Distribution box ( I ) Dosing tank (No)
'-' Percolation Test Results Performed,by---aA_txlEs 3 - 1--�.----- Date...... ..__.
Test Pit No. 1.....z------minutes per inch Depth of Test Pit______1.__._....... Depth to ground water.___--
(i, Test Pit No. 2................minutes per inch Depth of Test Pit-------1_3....... Depth to ground water-___-_--A......
Descr>ption of Soil Q� o ..r �ok�-�--._ 41. _S I t.l_0....2� Oc S�II
U _ o
� ,
W --------------------------------------------------'I...To....13--._...''�.W.................... ...................8.--'�._t3.------5��.__......--------•--- = _>
UNature of Repairs or Alterations—Answer when applicable_.._.
..-----•--------------------------------•----------------•-•------------------------•---•-------------•------=------•-•----------•-•------•---------------------------•---•-----------..._.........••--•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT?1: 5 of the State Sanitary Cod — The undersigned further agrees not to place th system in
operation until a Certificate of Compliance has been - s ed by oard of health. /
��1L�lil�d<� � l
Sined- ----------------•. ----- .......................... ................................
Date
Application Approved By__._..._.__ �� ' �z°— � _ '
Date
Application Disapproved for the following reasons:..............................................................................................................
..........................................................................................................................................................................................................
Date
PermitNo. ._.... ..��.� ......................... Issued_.......................................................
Date
�P�r�
No... .��. .a, Fss...-,. ........
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
........-t.. .N....OF.........
.....-.�-�t.'.A.1ZN.-C... A.91 -_�-:�-=.--..._..
Appliration for Mipa i al Workii Tomarurtion ramit
Application is hereby made for a Permit to Construct (L-f or Repair#( ) an Individual Sewage Disposal
System at' f
7- i cl --s L o l j
Location.Address or Lot No.
DA.Ni __............... .u. = L.L " aox �4Z aJ.. .4 .Q.1. ._.M ,_.: z _3
Owner / Address
a •--•--•-----. -_-------------------- --------------------------------------------------------------------------------------------------
Installer Address
d Type of Building Size Lot.� ..
50.4�.....Sq. feet
V Dwelling—No. of Bedrooms..................3_.....................Expansion Attic 60) Garbage Grinder (No)
pa•I Other—Type of Building ----NIA-_---_____-. No. of persons............................ Showers ( ) — Cafeteria ( )
al Other fixtures -----------------------------------
W Design Flow................ .. ......... .......gallons per person per day. Total daily flow------------=?.. .................gallons.
WSeptic Tank—Liquid capacityl';�QQ.gallons Length 1 __ Width_5.... Diameter.N f A...__. Depth.5.L 1} .. `
x Disposal Trench—No. .QUA........ Width.................... Total Length.................... Total leaching area....................Sq. ft.
Seepage Pit No._-___-I_____________ Diameter-------i.4....... Depth below inlet.....E?.......... Total leaching area.-Ala...sq. ft.
Z Other Distribution box Dosing tank Oio)
Pcrcolation Test Results Performed by-_.c__�_ .---... .�1.y.�.�. ..�._�-.�.._._.. Date...... ..
.......... ........
R ....
as Test Pit No. I.....2:.......minutes per inch Depth of Test Pit......1.3.._._... Depth to ground water......../lei------
44 Test Pit No. 2................minutes per inch Depth of Tesi Pit....... ..��.._.•.. Depth to ground water.......N/`A......
a ---•-------•--------•----••-•-•-----••-•--.......--• ............................................... --> ----------....,.----•----........i...
O
Cjl n �1 f 3dw: �t �0 1+ �`�v ,_ � Uc5 �IA�:c�I
Description of Soil--•--- --... - n �.r- t ? !!.t_._:.:...
-••....•. ...._
V ..._.....•••••••--••---•-•-•--------------•••••--•.3..F'- 3----r L_t_....1.... ..................•. �'l 1 t1 c :(e, ca�pG�•.19!d!._
...................................................= _..T.-_._J' ..... ............................................... ------ _
U Nature of Repairs or Alterations—Answer when applicable._____-����r
------------------------------- •---•--• -•..•••---
---------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
tY_e provisions of TITIL- 5 of the State Sanitary Cod —The undersigned further agrees not to place th system in
operation until a Certificate of Compliance has bee ed by oard of health. _
* ' r —f ,
/ Date
Application Approved By........ ...................................................
Date
Application Disapproved for the following reasons:---•--------------------------------------------------------•-------------------•------------•--...............
...-•-•--••••---•--•••--•------------•••-----------------------------•-••--••---------.......------------._.........----...-••---------------------......---------------------------------------....-•---
Date
..r
PermitNo.............mod........ ................................... Issued-......................
Date
,THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ALTH
............� �.OF................ ..........
Trrtifiratr of Tomphanrr
THIS IS TO CE IFY, That ! Individual Sewa Disposal System constructed ( ) or Repaired ( )
by------•...................... --- •. ..... .,. ..........--------------.....----------------.......--------------------...------.'--....----
ll Installer ' ,
ati•-a ...... __ .. --,- ----T�? ! °* l '----••-- = '"�"� -------------------•...---•-----------------...-•---------------
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._........9-....._.:'��-�.--' dated-.----- `_�� ►
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNC ION ATISFACTORY.
DATE.........................j Z •�--.. ........................... Inspector................. ........ .
THE COMMONWEALTH OF MASSACHUS TS
BOARD OF- HEALTH
OF
No... .... ....�..y
FEE......... ..........
�i��tar��l nrk� � �#rnr$Uan anti#
Permission is hereby granted...........`.. ..-..l� .......y_......__.t - - -- ........._.
------------------------••-••••---•-••-••.............
to Construct ) or Repair ( ) dividualA
12 ea a Disposal System
2
Street
as shown on the application for Disposal Works Construction Permit No.................... Dated...................... ....
,�..., .Q. -----------------------------------------
Board of Health
DATE--------------- ...........................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
LI H —L_
I -
N/F GEOR GE W. KALWEI T ET UX `N/F1- MARTHA DICKEY PROBATE 21912
A< VACANT CAN
C.Bd.
C fnd.
stake set 50.42 setsta
\ F
9
o N/ F WI LL I AM J. LEONARD ET UX
120 \Ne�� O
o N S' 6'diam.x 6'dee LEACHYNG PIT with 4ft.
R ERV HE 2 3 of washed s p
— tone all around.
9 All loom,subsoil and impervious material
shall be removed for a dis-tonce of 10ft. all
eoz around and below the l eaching system down
T- C96 to the strata of natural sand.
-kk 500 o The excavate impervious material area shall be
/oe 1 bockfi lied with can coarse sand or other `
/ � TEST SEANIK n t clean .npercolation
L 0 T 2 , 9e clean granular material having a
C.Bd. rate of less than 2 minutes per inch before
fnd and after being compacted in place.
BENCH MARK
N 37 ao�o n .�i / Top of bound
CID , oQoio Elev.=100.00(Assigned)
t0 \ �,
/
i v IO O r
o O\'a,
.w
O
co ,
96 n
LOT
5 047t S: F. _--
Proposed*
..;.
Well 5
rill ole
w a� .stake
28' I` w ; fnd. Stone set
�130%
F . s- stake 4�•� - �2 '
No � Rd�u seto LEGEND � } ��` ,oti
98 EXISTING CONTOURS . Ilo� Un d e f i n ed Town W a y S TREE
PROPOSED CONTOURS . v
MINIMUM LIMIT OF IMPERVIOUS MATERIAL REMOVAL.
I
i
f
Changed finish contours.C ed g f o tours.
8/20/85 Changed location of disposal system. R.S.
DATE DESCRIPTION Drawn by Checked by
NOTES I R E V 1. S 1 0 N S
1 ZONING DISTRICT: RESIDENCE F PLOT PLAN
2 . FLOOD HAZARD ZONE C
OF PROPOSED SEWAGE DISPOSAL SYSTEM
3 . ASSESSORS MAP NO . : III - 30 PREPARED FOR
4 . HOUSE NO . : 224 _
D A N A MIQUELLE
5 . THE NORTH ARROW IS DERIVED FROM RECORD PLANS
FOR LOT I ON HIGH S T R E E T
OR DEEDS . THE NORTH ARROW SHALL NOT BE USED IN
FOR ORIENTATION FOR SOLAR HEATING PURPOSES
WEST BARN STABLE , MASS .
6 REFERENCE: DEED BK. 4012 PG. 302. PL. BK. 291 PG. 4 4.
SCALE: 1 "_ 40' DATE: MAY 28, 1985
_ 7 . CONTOURS AND ELEVATIONS FROM ACTUAL ON THE GROUND INSTRUMENTtt`A `
SURVEY BASED ON AN ASSIGNED ELEVATION OF 100.00 holmes and mcgrath, inc . —
n
8. NO WELLS ARE LOCATED WITHIN 150' OF A PROPOSED LEACHING FACILITY. NO civil engineers and land surveyors
4 200 main street . 30255
�,. _ cove.
LEACHING FACILITY IS LOCATED WITHIN 150 OF A PROPOSED WELL, f almouth, ma . 02540
DRAWN: R.S.J. CHECKED: 1J,7-6> `;--
2 JOB NO .85089 DWG NO .36-2-21 [SHEET 1 of
I
SOIL TEST
BASIS
0 C DESIGN
e C I ^A) Finish grade above and ajacent to system shall slope o min.of 2% away from system DATE OF SOIL TEST 5-20-85 IggS.
1- G.J V'tl 4"diam.cost iron or Schedule 40 PVC pipe (install with tight joints.) TEST TAKEN BY TAwmic-ELLt
I. NUMBER OF BEDROOMS-3—(EQUIVALENT TO31G.P. D.) '
RESULTS WITNESSED BY-T cotitl."`t
20'minimum distance (building to edge of leaching system )
2. GARBAGE DISPOSAL UNIT NONE 10 min. disc PERCOLATION RATE--Z_MW./INCH.3. LEACHING CAPACITY REQUIRED 330 GROU
_G.PD. - .NO WATER:N°T• FNcouN-t -' D
4. SIDE AREA 264 . SO. FT , BOTTOM AREA 154-- S.Q. FT.
5. TOTAL. AREA PROPOSED 418 SQUARE FEET
SOIL LOG
6. PROPOSED` LEACHING CAPACITY 8 4 ' G.PD.
7 WATER SUPPLY WELL Ex i Access covers set at finish grade _�
-�! �--_ s ti n (Heavy Duty Metal Frame and Cover)
22'to elev. 94.5 _ Ns I N� 2
8. PRECAST, REINFORCED CONCRETE UNITS DESIGNED round Depth Soils Elev. Depth Soils Elev.
- O lot O 97
FOR H-10 LOADING Basement Floor F i n i s h g r a d e
_F.in • sh)0 F , ,
S=0.075 R movable cover. I 34 i`;n S P O m 8S a ed LOAM
Remco°vale C''2�- -S=0.0'5 -- 1 L .� 5o►L
• p s=0.04' /� - level I ; f = 5 u l L. 98 c.c�.M
' To p o stor�EL�4. L �r'� s��
,,. _35 "-9ro nd 3.5 S�tBSo�L 3.
NOTES: —__ / / o o,, layer of to to/8/�7 ,/ /
y o p ° ' /
in t0 0 0-o TO
aoW°Shed Stone.o SEPTIC TANK N / rn DIST /r / 000 'o e do ov °Oeo
I. NO CHANGE TO THIS SYSTEM SHALL BE MADE UNLESS r, - / c BOX. > , .o too >.,� // CLAY
• � �
m 'r' 1500 GAL. rn �� / �.0) / w ed ° ° °°washed,J.A / . / l ' / �/� / SANDM►X
APPROVED IN WRITING BY HOLMES AND MCGRATH, INC. �� Q' _ -- t ��. / �/ °' i if / St ne°', t6 Effective ;. Stone 'ads 'impervious 0 �• ' / 7 4-
.b. / a� / / �, • Depth e :Impervious material CLAY
2. A COPY OF THESE PLANS SHALL BE KEPT ON w °°''° ° ' °' " / t 8 tx 89
W ��' j /,� / '/W � / ao °e" -�a removal all around.
SITE DURING CONSTRUCTION. Foundation e c c c c c /� �a ; °��a, • Precast concrete :b�o °o//
Design by others LEACHING PIT Qu•�E 1 =8
3. A COPY OF THESE PLANS '! SHALL BE FURNISHED
Natural Sand > '
TO CONTRACTOR INSTALLING THE SEWAGE DISPOSAL 4ft. 6ft.diam. Oft. Natural So w �. SAND rah tQ�
4ft of 3'4 toll/2 washed stone 13 88 t3 84
SYSTEM. P R O F I L E S all around precast it
4 HAY CONSTRUCTION E IPMEN HALL NOT TRAVEL — p providing an
effective diameter of 14 ft. El 64.
HEAVY EQUIPMENT S Not to scale. Bottom of test hole
OVER DISPOSAL SYSTEM DURING OR AFTER CONSTRUCTION. -
5. SEWAGE DISPOSAL SYSTEM SHALL BE CONSTRUCTED IN
ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRON -
MENTAL CODE. -
6. BEFORE BACKFILLING THE SYSTEM, THE CONTRACTOR -
SHALL NOTIFY HOLMES AND MCGRATH, INC. OR THE BOARD OF
HEALTH AGENT TO INSPECT THE SYSTEM AS CON
STRUCTED.
_ All outlet t from the distribution box shall
10 6 _ Outlet pipes
beset level for of least`2ft.from the box.
Knockouts
INLET -•� OUTLET-�•- _N
�-
r •. ::-: 7
All access Manhole covers for Septic Tank,
INLET-!E:: OUTLET 1
/ •.. p
• � Distribution Box and/or Leaching Pits set . ':�' o.� . �.->
.�. _ more than 12"be low f i n i shed.grade shiol l be Outlet
ao raised fo within 12"of finished grade. Knockouts
_ in Heavy duty metal frame a cover or reinforced
concrete cover over Ts where required.
,� - Changed Profile invert elevations afinish grade. per,
•- •— -- 2-0 I-2 6/20/85 Chan ed asi s of Design . v�.
Concrete block DATE DESCRIPTION Drawn by Checked by
STEEL REINFORCED PRECAST CONCRETE _ - °f - _
- Brick masonry. ,•;,.f,, Concref66 cover.' °.'> 2" ` :Conc•.'cover:�� R E V I S 1 O N S
�3., _--- Removable covers---- 3 f -=  "' `� a INLET
;._.,a.- ,�. 4I�„ INLET �- - � ' Outlet y_ Dutlet PLOT PLAN_ - DETAIL SHEET
3 min.clearance required --------- -.- ,� ,� 1 1 LE -+-- 0, c
t' --}-( T T Knockouts . .� .
2'inin-inlet to outlet 6"mm INLET T ,.: 2" 2 mun. _ ;I KnOckOutS
ItvLErLET l3 OF PROPOSED SEWAGE DISPOSAL SYSTEM
Liquid level -- 14„ ,, i � 6 u? ; 6"min
►o m11
in. PREPARED FOR
t - min: , _ —
_ D A N A M I Q UEL` LE
�'' FOR LOT I H I G 'H STREET
O� -
-- T TYPICAL DISTRIBUTION BOX WEST B A R N S T A B L ,, E MASS .
J -�J SCALE: I I'-0" Scale : As shown Date: MAY 28, 1985
1 holm es and m rat h F -ho s cg
} civil engineers and land surveyorsA.
-- 10'- 6 �--- -- 5 - 8 --- 2W morn street ci i�55
TYPICAL 1500 GALLON SEPTIC TANK _ fol-mouth , ma.02540
SCALE:3/8 1'-0"
Drawn By R.S:J. Checked By �.AC� �IoNas.
� f
JOB N° 85089 :-DWG.N'136-.2-2! SHEET 2 OF 2
- _ _