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HomeMy WebLinkAbout0027 HOMESTEAD LANE - Health 27 HOMESTEAD LANE WEST BARNSTABLE A = 109 -065 I I l I Commonwealth of Massachusetts Ole Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane,West Barnstable, MA Property Address William McEvoy 28 Day Street F Owner Owner's Name requiredfo is Auburndale MA 02466 6/12/2019 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. Inspector Information !%S 1 (0 filling out forms on the computer, ,Joseph M Martins use only the tab key to move your Name of Inspector cursor-do not Accu Sepcheck use the return Company Name key. d Drive � Company Address ess South Dennis MA 02660 Cityrrown State Zip Code 508-385-5891 S1 147 Telephone Number i License Number B. Certification I certify that: 1 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. ❑ its / 6/26/2019 Inslecrors Si natu(e 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.7QW018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form sP` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owners Name requir required is Auburndale MA 02466 6/12/2019 required for every City/Town pace. 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"Conditio Pass"section need to be replaced or repaired. The system, upon completio of the rep ce t or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, r the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or t septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltr on or tank failure is imminent. System will pass inspection if the existing tank is replaced with omplying septic tank as approved by the Board of Health. *A metal septic tank will pass inspectio if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is ss than 20 years old is available. ❑ Y ❑ N ❑ (Explain below): I t5insp.doc•rev.7/28I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name info.-oration is Auburndale MA 02466 6/12/20 required for every page. Cityrrown State Zip Code Date of spection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pa with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high st is water level in the/distribution box due to broken or obstructed pipe(s)or due to a broken, s led or uneven dist ibution box. System will pass inspection if(with approval of Board of Healt . ❑ broken pipe(s)are replaced ❑ Y ❑ N ND(Explain below): ❑ obstruction is removed ❑ Y ❑ ❑ ND(Explain below): ❑ distribution box is leveled or rep ced ❑ Y N ❑ ND(Explain below): ❑ The system required purr ing more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspect' n if(with approval of the Board of Health): ❑ broken pipes re replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction ' removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Eval tion is Required by the Board of Health: ❑ Conditi s exist which require further evaluation by the Board of Health in order to determine if the sy ern 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 Forth:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane,West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. Cityrrown State Zip Code Date of lnspedion 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 a salt marsh b. System will fail unless the Board of Health(and Public Water S pplier, if any) determines that the system is functioning in a manner that pro is the public health, safety and environment: ❑ The system has a septic tank and soil absorption system AS)and the SAS is within 100 feet of a surface water supply or tributary to a surface ter supply. ❑ The system has a septic tank and SAS and the SAS ' within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and a 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 a lysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and a presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page.e. Cityrrown 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 Y2 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 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must se ry 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 f t ollow' g, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of urface rinking water supply ❑ ❑ the system is within 200 f of a tributary to a surface drinking water supply ❑ ❑ the system is located ' a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a apped Zone II of a public water supply well toinsp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "WW" 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name inquired for is Auburndale MA 02466 6/12/2019 required for every page. City/Town 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 brea out? ® ❑ Were all system components, a Ing t e 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.7/2612o18 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�' 27 Homestead Lane,West Barnstable, MA Property Address William K.Evoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: 1000 30ALLON SEPTIC TANK CONNECTED TO A 6'X6' LEACH PIT WITH 1-1.5' STONE Number of current residents: 2 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 ears usage d WELL WATER 9 ( Y 9 (gp ))� Detail NO METER Sump pump? ❑ Yes ® No Last date of occupancy: 6/12/2019 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth: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 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per 7gpd) 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: PER BARN WWTP: PUMPED 10/24/2019 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.7/262018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. Cityrrown 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): NO DISTRIBUTION BOX Approximate age of all components, date installed(if known)and source of information: INSTALLED 1976.43 YEARS PER BARNSTABLE HEALTH DEPT. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: IN FLOOR 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.): NO EVIDENCE OF LEAKAGE. t5insp.doc•rev.7/2612018 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: APP 8.5 X6X5 1000 G Sludge depth: 7 INCHES Distance from top of sludge to bottom of outlet tee or baffle 27 INCHES Scum thickness 0 INCHES Distance from top of scum to top of outlet tee or baffle 6 INCHES Distance from bottom of scum to bottom of outlet tee or baffle 14 INCHES How were dimensions determined? CORETAKER Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): HAS CONCRETE INLET TEE. HAD CONCRETE OUTLET TEE THAT WAS CRACKED AND REPLACED BY INSPECTOR WITH PVC TEE AND GAS BAFFLE. LIQUID LEVEL IS 481,AT OUTLET INVERT. NO EVIDENCE OF LEAKAGE. t5insp.doc-rev.72612018 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 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) 7. Grease Trap(locate on site plan): Depth below grade: N/t Material of construction: ❑concrete ❑ metal ❑fiberglass polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scu/invert, ee or ba e Distance from bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping , inlet and outlet tee or baffle condition, stru I integrity, liquid levels as related toence of leakage, etc.): z Ytl.-1 8. Tight or Holding Tank(tank must be pumped/assM )(locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiolyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 15insp.doc•rev.MAM18 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane,West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. 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 alar/ and flo switches, etc.): fr / *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 N/A 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.): NO DBOX FOUND, CONFIRMED W CAMERA. Linsp.doc•rev.7/26/2018 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 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: /urtenances, No* Alarms in working order: No* Comments(note condition of pump chamber, condition of pumpetc.): *If pumps or alarms are not in working order, s tern is a conditional pass. 11. Soil Absorption System(SAS)(locate on a plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 1 6'X6'W 1-1.5' STONE ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.MM018 Title 5 Of ial 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 � 27 Homestead Lane,West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. Cityrrown 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.): LEACH PIT WAS DRY. HEAVY STAINING TO V ABOVE LEACH PIT BOTTOM. MODERATE STAINING TO 3.5'.ABOVE IS SOME VARIABLE LIGHT STAINING AND VOIDS IN OPENINGS. 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 draulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2&M18 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane,West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. Cityrrown State Zip Code Date of I pection 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 f dure, level of ponding, condition of vegetation, etc.): IVA / XI/ Z \-V t:insp.doc-rev.7/28f2018 Idle 5 Official Inspection Forth:Subsudace Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane,West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is Auburndale MA 02466 6/12/2019 required for every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 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 / W 4qo' / 3 : o ftsp.doc•rev.7/2612018 We 5 Official Inspection Form Sdasurface Sewage Dispose►System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane,West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale MA 02466 6/12/2019 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 98 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: GOOGLE MAPS, CAPE COD COMMISSION GROUNDWATER CONTOUR, FRIMPTER You must describe how you established the high ground water elevation: SITE IS 134'ASL. GROUNDWATER CONTOUR IS 28'ASL WITH A MAX RISE OF 8'. GRADE TO SAS BOTTOM IS 9'. SEPARATION MATH: 134-(28+8+9)=89'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Homestead Lane, West Barnstable, MA Property Address William McEvoy 28 Day Street Owner Owner's Name information is required for every Auburndale: MA 02466 6/12/2019 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)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached Fo-15: Explanation of estimated depth to high groundwater included t5l.nsp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 rig - LO ION SEWo,C;E PERMIT UO. IW574LLER S ►J&ME ADDRESS BUILOE Q &MF- �- AD ORF- 5 DD,TE PER" T ISSUED =�= N — —` D ATE COMPLI &MCE ISSUED ; 7- /=76 d e o� �Y q $10 .00 No...... -�-•• Fps............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !ti A- ........... .......... . .... ... .............O F.......................................................................................... Appliratiun -fur 'Mipoiial Workii Towitrurtion Vrrniit Application is hereby made for a Permit to Construct (X ) or Repair ( } an Individual Sewage Disposal System at Homestead Lane, "TRAILVIEW"_,, W._Barnstable Lot 69 ............................................................ -Mar aret L. o`a Address or of No. 2116 •---------g•-------------------• G'.ui`��-•-•----•------••---...-•------•--..........-- 2--.-..---MarlboroucJh Sit.-,Boston, Ma.....0.... Owner Address W Norman AVotte 176 Main St Sand a ------------ ---------------------- .----- --------------------------------------•-----. *.w Sandwich, Ma 5 Installer � / Address UType of Building "``v''�1`j Size Lot....-35 200 _ Sq. feet Dwelling—No. of Bedrooms--------- :...--------------Expansion Attic ( ) Garbage Grinder aOther—Type of Building ---------------------------- No. of persons..---------------..-..._..-- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------ •----------------------- - •. W Design Flow................ .! _, :__..gallons per person per day. Total daily flow......... ._..v_cd............gallons. WSeptic Tank l—Liquid capacity/4w)-gallons Length................ Width................ Diameter................ Depth.._._-.-...._. x Disposal Trench—No..................... Width.. --........ Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No-------------4----- Diameter..../ ..-.- - .. Depth below inlet..... Total leacltitig ttre:t...2 U1---sq. ft. Z Other Distribution box Dosing tan ) e Percolation Test Results Performed b Aln Jones 6-9-76 aY - ------------ Date............. Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water--------.------.---_-. f� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--------------------- ---------------------- -----•-•-•---------------•-------•-•------•-•--•----........-----------•-----.......................................................... 0 Description of Soil........See--- ttached--percolation_•test_-_re_gort--------------------------------------------------------- x U W --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------••------------------•-•-------------------•-----------•----•--•--------------------------•-------------------------------..-.-..-------•--------------------------------------•--•------------.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha&;I en issu by of lth. 4 / Signed--- tit.la,e.4►:iw�a - - - ---- ------------------- t --- Application Approved BY Da e �----�----------------•-•-••-----------••-•---------- - -•---------.._..--•-------•- ------------....._--D --------------- Date Application Disapproved for the following reasons:---•---•----------•-----•-•---•---•----•-----------------------••---------------•-•--•------------------•------- --••--•-••-•-----•------•---.....--•-------------------------------------•--•-•-•---•---------------•---------------------------------------------------- ••----•-------------•------•----------•--.----- Date PermitNo.......4-7-7.................................. Issued........................................................ Date s No.......... ?... F1m�....$10..0.0..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................................................... Appliration -for Uiipoottl Eorks Tonotrurtion Vantit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: Homestead Lane, "TRAILVIEW", W.Barnstable Lot 69 ---•-------•-------------------------------------------------------------------------•---•-•-----. ------•-•----•----••---•----••--••--•---•••-•-••-••----••-•-••-•--------•-••--•----•-•----••--- Margaret L. �uiilndAddress 272 Marlborough°rS :;Boston, Ma. 02116 •---•--------•----------------------•--•----•-----------...-•---------------._...-------•--•----•- ••-••-•-••-----•---•---•--•-••----•-•••-•••••••••---••------•---••---•-•-•--••......••---•---•-_.. Ad ess, a Norman Ayotte Owner 176 Main St. , SaAndWich, Ma. 02563 Installer Address Q Type of Building , ',04 Size Lot....- 35,200 Sq. feet aDwelling—No. of Bedrooms._........0�..,, ................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons------------- -------------- Showers ( ) — Cafeteria ( ) QOther fixtures_..........----- -----------------------------••------ -------------------------------------------------•--------------------••-------•---------..._. W Design Flow... .............. S _....._LL_.��..,,.,,gallons per person per day. Total daily flow......_...:'(�....r-..----...........gallons. WSeptic Tank Liquid capacity- ------gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width-------------------- Total Length......... Total leaching area------..............sq. ft. Seepage Pit No....... .......... Diameter---------F...... Depth below inlet.................... Total leaching area----v.l-.sq. ft. z Other Distribution box ( ) Dosing to ( ) Oh- �C�. Man Jones 6-9-76 W Percolation Test Results Performed bY-----------------......................................................... Date.-•------•---------------------•-------- a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.....-----.-..------ Depth to ground water------------------------ ix ------------------- ------------••••------....-••----•----------•-•..............---•---•-----•---•.......................................................... 0 Description of Soil.........See attached percolation test report ------------------------------- x U ' W i x --- ---------- ------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the Mate Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliances has been issued by the board of health. Signed-------------------------------------------------------------------------------------- ----- �/� Date Application Approved BY �� / ----------------------------------------------------------------------------- Date Application Disapproved for the following reasons:--••---•---•----•-•-------------------•-----------------------•-•-••--------------•----------------------------- -•••-••.....................•---••----------•-----------••-•-•-------------••-•••---•-•-----•-----••--•------••-••-•--••.•-•--••---............•--•--------------....--------------------------- --••-- vv�� Date Permit No.. � Issued ----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF �a 01ertifirate of Tomplianre THIS IS TO CERTIFY, Th t the Indivjdual Sewage Disposal System constructed ( ) or Repaired ( ) bY•-----••--.-•--•�e)/i fir % / C.- .....................................................((����' ........................ •--------------•--......----------------------------------------------------.........-•••••- at--------! U/-• C/ ! b,0'1r i/�%�? � Z-A/. �staller �,owl-I L/�G"/Ci _. r:/- �Ai�f,/ i 71,4, .: ... has been installed in accordance with the provisions of Article XI of The State Sanitary Code as desc i ed in the application for Disposal Works Construction Permit No.....-�p EGG dated. = f THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUON SA �ORY. DATE Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH liar,a ....................... .. ..........O F................ _............ `..:....-.. ................................... No......................... FEE........................ Dinvo,ittlFPrk-q Q10 x �tioat rrmit Permissionishereby granted---------- -----------------------------------------•---•-•--•--Y.......................................................................... to Construct (/ or Rep air��, an h/&v iduaal Sewage Disposal System atNo.... •• -----------------------------------••--- -•-•-----•--...-•••--•••/-r1.r--- / Street r - as shown on the application for Disposal Works Construction Permit No....._: �_ Dated.. /- �L DATE------------------------------------------------------------------------------ Board of Healltt1i + FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ALAN W. JONES & ASSOCIATES CONSULTING ENGINEERS CARLETON DRIVE EAST SANDWICH. MASS.02537 TELEPHONE 888-3154 TEST PIT AND PERCOLATION TEST 9 June 197 � To : Barnstead Builders, Inc. Personnel Present: Norman Ayotte Route 6A & Tupper Rd. Paul Murray Sandwich, Mass. 02563 Alan W. Jones Re: Lot ##69 Test Location: . 110' into lot from Homestead Lane Homestead Lane W. Barnstable, Mass. layout 0'Off Topsoil Subsoil and rock 011 Average Percolation Rate : 1" drop in less than 2 min. 06" Firm, fine to medium, clean, yellow sand SN A14s& o� ALA G S tP c o J S N U No. 0 O 12,0" EP >`� No water encountered N a1 , Water levels indicated, if any, are those observed when test pit was excavated and do not necessarily represent permanent ground water levels. r i lye F +� �.?;: �•- . . � a _: i _ .. CIL SN Vi VA iv x ,t tic, - 1 lZI IV r _ •+`V" G'"•t;«�'°���.i 1r f ��ll� � y�t.lk~ !4`t�t1�1,l1"�rf� 1��C;. r�Y'r�1 C ��.f,w', ��tg�F�...�'�4�--! ✓ ��4.°6iu`��"a•�ar��...� '�-"." � iij T' I�,t i 1'' .1-�J. riLr(m--?i �',;,* i . ' , 'l��'' F�.'y! `�"•. `�'1� r �` - J�°,r ,,��!i,�ll 1 `✓�S;trr�r�'.1 t�i`�� �� ��_'..�i'�' ; ��;�f..=''`}�?41�,!4`i ��^� _ - (S ALA Nx 317 r „-..x ....� i••1 ff; fir•^' � �' r iY~� r'r t �i�, '-�'�x,�.�(k. �;, a1,�+;��,ter i7.r�.1 ,: x '� fit, a, � �� �r�a -�,�'�t�r�•� � ,.�-��"-{t�E>� r. F t N n� r t ry e r_ VA JA NtA t 71 ����fi� ! `� • �={�,r�;� W � vim.•����:� ��� �t,r°' f'1�r1� i� ^"�)t�{"f�Ma. r �.1��1% °"° r..� .�f� .w 1•�! ! f, r ` �"' � -- r f �t', Ft�r'= .-'�'��'' t �I� T��+"1,, t/�/•�1 ``".,.TT 9��'''�� �1 � /a�;-�' `• _ /11''jf�I rr'���t�`.� �� �'��1�L �r..,tr '!)�`� ?_'i""�'l�r'I-`.� ���ti.,.� t.. t ".-- ..__ _.._ - - -`�•'^^"""' Y err 4Cf. i'7'f_-f *;p''e;} q r W ko t - ... - • _ e - - s. • � q I a J i .! CB w - : So • yr ; I r i Lq 7 C RX 7Y),:�j" ),1.07- pozlml OcAT/0IV- BRRNV 5TfJB.4E SCALE: /„^So' REfERE/VCE acING LOT 2 /95 SHOWN OM PLAN )c'oR MARy T 57',F6NER- .DATED JUME 22, 197'6 REcokDED / M TR,F $ARNSTAB.CE coUAITY RE6IS7-XY OF DEEDS JAI I'LRN BOOK 90q ,t)�6E �S i / HEREBY CE,eT/Fy TNAT ?HE B U/L DI MG S P O W A/ O NJ T P I S t�,L A N__.. _ _ far _ _ -L44 _ � o i ✓S LOCRTE"D ON THE GROUND As -SHOWN HEREOnI AND TPR-r l T DOES C O N FO k M TO THE o Z o N/NG By- LAWS O F Tr qE 7o w N oG" i 3ARASTA84C W HE /V CONSTRUCTED o �J o v9e .L0 V./ a- nd Co. i �PVSN of M 59 /5 GEO N 4 OW R. OISTC FO ND. I , • 0 37,500 PTM 39:32- o o !, � N C.B.t fg o•3h o•o 0, 3 FN,9- M3- 0055 . _ _ _ -_-_ _-_ ...