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HomeMy WebLinkAbout0011 HOWLAND LANE - Health 11 Howland Lane West Barnstable J j A= 112-001 Ilr r TOWN OF BARNSTABLE LOCATION 11 H061LAND LANE SEWAGE # 2000-301 WEST BARNSTABLE -` VILLAGE ASSESSOR'S MAP & LOTA��00 ELLIS BROTHERS CONST . CO . INSTALLER'S NAME& PHONE NO. 362-6237 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (3� Too (size) oo k i(s-xk f NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER f BUILDER O OWNER 46 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: vo VARIANCE GRANTED: Yes No �� .�. -- :� �. � z \ O �� e \ rs _.. .� � _ ._ :� �� `f .rye t�m96 'l(�'t�a�"� v✓ PA-001 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Howland Lane V Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 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 51ay- 15 $ on the computer, Daniel Hawkins use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Company Address Sandwich Ma 02563 City/-rown State Zip Code raaae: (508)477-0653 S114324 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. FM Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins `Digitally signed by Dan Hawkins Date:2021.02.22 12:20:14 asoo 2-18-2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City/Town 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: The system was in working order at the time of inspection. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts : @ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ~ -- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 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 El El clogged 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �w Title 5 Official Inspection Form ! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 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 '/z day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El 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. ❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ E] 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is required for every West Barnstable Ma 02668 2-18-2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to an question in Section C.5 th y y y q a 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 ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ El Has the system received normal flows in the previous two week period? ❑ El Have large volumes of water been introduced to the system recently or as part of this inspection? O Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ F-1 Was the facility or dwelling inspected for signs of sewage back up? E ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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: El ❑ 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)] l5insp.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 l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c �, � 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is west Barnstable Ma 02668 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System.Information 1. Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/GPD Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes El No Does residence have a water treatment unit? ❑ Yes Q No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes RI No information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: ***WELL WATER*** Sump pump? ❑ Yes ❑■ No 2009 Last date of occupancy: Date t51ns.doc•rev.7/26/01 2 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal •P P System Page 7 of 18 P 9 Po Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- date of last pump is unknown 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 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 el,05. 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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: 2000 per permit Were sewage odors detected when arriving at the site? ❑ Yes X No 5. Building Sewer(locate on site plan): 4'6" Depth below grade: feet Material of construction: ❑cast iron ❑■ 40 PVC ❑other(explain): >165' from well to SAS Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts 1 = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 11 Howland Lane . Property Address Christine Kelly Owner Owners Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 36 r n Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) i If tank is metal, lis t e: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dim . 1500 9 allons Dimensions: 311 Sludge depth: 3311 Distance from top of sludge to bottom of outlet tee or baffle 1 of Scum thickness II 519 Distance from top of scum to top of outlet tee or baffle 1611 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. Roots growing around riser were observed and may need to be removed in the future. t5insp.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 JJ/ 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA 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 Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments --� 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is required for every west Barnstable Ma 02668 2-18-2021 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 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): Or' Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.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 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City;'Town 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.): NA * 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: (2)500 gallon chambers El 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 9 Po Y 9 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is west Barnstable Ma 02668 2-18-2021 required for every page. City/Town 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.): The SAS was in working order at the time of inspection. Leaching was dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert layer Depth of solids la P Y 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.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 �I Commonwealth of Massachusetts Title 5 Official Inspection Form !� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 11 Howland lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City/Town 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 rta wr►o sARxvsrasl.� ... _. ......_.. i LCk_-A7ION 11 HOWL AND LANE 5 BARSTAQLEWE an 0YLLAG8 02[?0-0-3Of ' INSTALLER NAME 6 pEICYNE A10_E� IS BRDTFOLips CoNsr. .co. o SEPTIC T++AIVK.CAPACITX �-�- LEACkUNGi.PaliCILITY:LICFA�j NO. DB SEDROf)Dt3��F'7I;IVATE WELL oR PUBLIC WATER i SUIL]C2ER O_ t)M*NER_ 1 OATS PERMIT ISS23EI?b aA'FIi Ct?MFLIAlYCBISSUfiI?- YAfEIAIVCE GRAI!rTBD: Yes po 4 1 � rco f '� r j i 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 1 11 Rowland lane Property Address Christine Kelly Owner Owner's Name information is west Barnstable Ma 02668 2-18-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: M Check Slope ❑■ Surface water ■❑ Check cellar M Shallow wells Estimated depth to high ground water: No GW @ 12'feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record Permit dated 6-19-2000 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: A permit on file at the local Board of Health was used to determine high groundwater. 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 Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 11 Howland Lane Property Address Christine Kelly Owner Owner's Name information is West Barnstable Ma 02668 2-18-2021 required for every page. City/Town 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 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 Citizen Web Request Page 1 of 1 Iar.,. � TIQ s SAIL\3TMILE, +r` «}3. 6.e�� Citizen Request Management . ♦ f�D � I Request ID: 59860 Created: 12/19/2018 8:46:40 AM Status: Closed Assigned To: Lavelle,Timothy Health Office Anonymous: No Category: Chapter 108 }}j Hazardous Materials y E.C. Date: 1/7/2019 Created By: Tripp,Vanessa Citations: +� Health Office Time Worked: 4.00 Response Time: 2.00 Request Location: 11 HOWLAND LANE West Barnstable, Ma 02668- Parcel Number: Map: 112 Block: 001 Lot: 000 Request: Home heating fuel leak, 5 gallons and under. Request Work History: Entered on 12/20/2018 8:49:41 AM On 12/18/18, a small leak in the 225-gal fuel tank was discovered by workers at the house when they smelled oil and noticed that the heat wasn't working. Scudder-Taylor Oil was notified as well as the West Barnstable FD.The leak was plugged until the remaining oil was transferred to a temporary double-walled AST which is located on a back porch.The FD spread speedi-dry and sorbent pads to absorb oil which had already leaked.TL investigated incident on 12/19/18.The above ground tank is located in the basement on a concrete floor. Sorbents were observed in an area approximately 9'x5'. Some wicking of oil was observed on the bottom of the wooden stairs. There is a floor drain but the oil had not reached it. Scudder-Taylor was contacted to inquire about oil deliveries.The last delivery was on 12/10/18, and prior to that, oil had been delivered on 9/21/18,The last delivery was 193 gallons to fill the 225-gal tank. Approximately 215-220 gallons were pumped out on 12/18/18.Therefore, based on visual inspection and records provided by Scudder-Taylor, an estimated 5-10 gallons of fuel had leaked.The owner of the property and Scudder-Taylor were notified to clean up any remaining fuel before installation of the new tank. The installation will be witnessed and inspected by the FD. http://itsqldb/CitizenRequest/WRequestPrintPub.aspx?ID=59860 12/20/2018 -Dec. 19. 2018 9; 06AM No, 0148 P. 1 WEST BARNSTABLE FIRE DEPARTMENT 2160 Meetinghouse Way P.O. Box 456 West Barnstable MA 02668 www.westbarnstablelire.com Joseph'V.Maruca Fire Chief Emergency: 911 Business 508-362-3241 Fax: 508-362-3683 FAX TRANSMITTAL COVER SHEET THERE ARE Z PAGES INCLUDING TIES COVER SPEET DATE: TO: I I ri I—AV EL[.46:" BA(rrjS ALA G-rd_ FAXNO: 790 ( 3o� FROM; 31 L-U 1-ni �y COMMENTS: CONFTDENTIAI.YT'Y NOTICE: The facsimile transmission may contain confidential information belonging to the sender which is legally privileged and which is intended only for the use of the individual or entity named above. Any copying, disclosure, distribution or dissemination of this information or the taking of any action based upon the contents of this communication is strictly prohibited. If you have received this transmission in error, please notify us immediately by telephone and return the original transmission to us by mail or by delivery to our address as listed above. U19239 2018 f9: 06AM LJJd 1 tole I it I 118-0000638 I 000 0148-1et<P• 2 �I _i ° ❑Chenge Basic MID * State* Incident Dare * Station Incident Number * "posure ONO Activity Check thla box co Indicate thac eh•a4dre-e fog Chia inoldenc Sa provided on the Hildihad Fire Census Tract $ Location* �Ncdulc In Scotion h"Alternative Location ap=oifichtion ass anly for Vildiand fik-a. I ®Strout address 11 " 1Howland I ILNJ ❑Intersection Number/Kilepost Prefix Street or Highway street Type Suffix In front of --- — - - ❑Rear of �J IWest Barnstable —_I rtA 1 02668— Art./suite/Room city stare Zip Coda I]Adjaaent to 1 I []DirectionsCross street or directions, as anglicable C Incident Type * El Date 6 Times Midnight is 0000 E2 Shift & Alarm 413 10il or other combustible liquidl Check boxes if Month Day Year Hr Min Sec Local option dates are the hcident Type same as ;"amALARN always required 10 1 I I �T1 T I Date. Alarm * 18 2018 16:56(00 L L_1 C J p Aid Given or Received* pl,,, ,L: alarms District 1 ❑MUtual aid received ARRIVAL required, ubleaa canceled or did not arrive Arrival* I 1A 1 1131 1 20181 17:I 03:00� �3 2 Automatic aid ruCv. Their rbTb Their 3 ❑blutual aid given Brats CONTROLLED Optional, Except Lor aildlend tares Special Studies 4 L_I Automatic aid given 1 1 ❑Controlled L-i L—J I I I Local option 5 Other aid given Their LAST UNIT CLEARED, required except for wildland fires 1 Incident Number Last Unit Special Special N ®None 141 Clear®d ( �2( 1 181 1 20181 17 1 •33 I.00 Study IDN study Value g' Actions Taken * G 1 Resources * --I I G2 Estimated Dollar Losses 6 Values Check this box and skip this }[ I,OSS95: Required for all fires if known. Optional - ---- - section if an Apparatus or -- ------- — — 86 1lnvastigate I Personnel form is used. for non fires.. Iron Primary Action Taken (LI Apparatus Personnel Property $1 1 111 000 11 000 44 1aa$ardoue wateriale I Suppression Contents $1 000 , 000 1 ❑ Additional Acclon Taken (1) M49 1 I PRE-INC=ENT VALUE. Optional �� 1 Other 0002 0011 Property $1 000 , 000 82 Notify other agencies. I � J Additional Action Taken (3) 11 include box if resource counts include aid received reaonrcei. Contents $1 , 000 , 000 ❑ Completed Modules Hl*Casualties❑None H3 Hazardous Materials Release I Mixed Use Property 1]F_re-2 Deaths Injuries N ❑Norio NN Not Mixed ' II I 1 Natural Gas: .le,.1..k, ...,..,,,elan-x.a� ..es.e. l0 EducatAssembio use etructuru-3 Fire 8ozvico I� I� ❑ 20 Education use ❑civil Fire Cas.-4 2 []Propane gas: a1 lb. t.hk 1.•S.hwe.aao pain) 33 Medical use ❑Fire Aerv. Caa.-5 Civiii 3 ❑gasoline: v..saa.s++.r d.k e=P-W-a}-oont.sa 40 Residential use ❑EMa-6 4 Kerosene: f a 1-4.0 wipe==p-hbl• 51 Row of stores Detector 53 Enclosed mall ❑Ba2Mat-7 Required for confined Fires. 5 ❑Diesel fuel/fuel oil:vehlel.iQ i r-k ek kekl.bs. 58 Hue, 6 Residential ❑Wildland Fire-8 1❑Datmetcn alortad eecupanta 6 []Household ®olventr: ft -/-tFio-.pill, ci-.no ehiy 59 Office use ®Apparatus-9 7 ❑1dotor oil: f=e,a.,lei,,.,=v.=ts1.em,t-inc 60 Industrial use MPereannel-10 2❑Datactor did not.Sort them 8 ❑paint: crow paint oand totaling< SD gallona 65 military e use ❑Arson-11 UQ unknown 0 ❑Other: "-i-L u-.x-e.eeld,.=.q.s=.d e=.psu>sags., 00 Other mixed use as `7 Property Use* Structurea 3411]Clinic,clinic type infirmary 539 ❑Household goods,galas,repairs 342❑Doctor/dentist office 579 []Motor vehicle/boat sales/repair 131EIC+urch, place'of worship 361❑Prisoa or Sail, not juvenile 571 El Gas or service station 161❑Restaurant or cafeteria 41919 1-or 2-family dwelling 599 ❑ Business .office 162 ❑Ear/Tavern or nightclub 4291]Multi-family dwelling 615 El Electric generating plant 213 []Elementary school or kindargarton 439 pAooming/boarding house 629 ❑Laboratory/science lab 215 ❑High school or junior high 449❑Commercial hotel or motel 700 ❑Manufacturing plant 241 [:]College, adult education 459❑Residential, board and care 819 ❑Livestock/poultry storage(barn) 311 ❑Care facility :fox the aged 464❑Dormitory/barraoka 882 []Non-rosiduntial parking garage 331 []Hospital 519 Food and beverage sales 691 warehouse Outside 936❑vacant lot 981 ❑Construction site 124 ❑PlaY9round or park 938 ❑Graded/care for plot of land 984 p Industrial plant yard 655 pCrope or orchard 946 Lake, river, stream Lookup and enter a property Use code only if 669 []Forest (timboxland) 951 (Railroad right of way you have NOT checked a Property Use box; 807 ❑Outdoor storage area 960 [:]other street Property Use 1419 919 []Dump or sanitary landfill 961 ❑Highway/divided highway 931 ❑Open land or field 962 ❑Residential street/driveway 11 or 2 family dwelling 1 NFIRS-1 Revision 03 lrn� Weer 3arnatable Eire Dept 01923 12/18/10 19-•000063e L Dt-c. 19. 2018 9: 05A*mi DD YYYY' No. 0148 P. 301923 U12 18 2010 11 19-0000638 000 . _ LeteD * stage* Incident pate * station xecsamt Number * Exposure .* Narrative Narrative: on 12/1B/18 at 16:56:00 dispatched To 11 Howland IN /West Barnstable, MA 02668. The location is a 1 or 2 family dwelling. The incident was determined to be a(n) Oil or other combustible-liquid spill: —.. -- --- ----------- ...- -._..----- — ------ 17303:00 arrived on scene. - . The following actions were performed on scene: Investigate Hazardous materials leak control containmen Notify other agencies. Units responding were: Unit WE-294 responded. Unit WS--287 responded. 17:33:00 all units back in service. Called by Scudder-Taylor oil Employee on location for possible home heating oil leak. On location, employee reports 225 gal tank in basement was filled with 195 gallons oil on Dec 10. Today, Dec 16 the oil company was called out for "no heat" call at property. Home owner not present at residence. Today, prior to WBFD arrival,, oil company only able to add 5 gal to tank befofe tank topped off. oil company noticed two small leaks in oil tank, with oil on fieldstone basement floor, (approx 1 gal. ) Company applied patches to tank, apparently controlling the leak. 294 crew applied speedy-dry to oil on floor. Unknown how long tank was leaking and what qualtiy leaked out of tank over time. Company tranfered oil from home tank to temporary tank. board of Health notified, with Deputy Paananen to follow up. Home owner Info: Christine Kelley. 35 KEnwood Drive, Worcester, 016051. Home: 508-853-0756 Cell: 508-509-6809. Cottrell 421. West Barnstable Fire Dept 01923 12/18/18 19-0000638 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c 11 Howland Lane Property Address Stephan Belfit Owner Owner's Name information is required for West Barnstable MA 02668 12/03/09 every P9 a e. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information ' When filling out 092) forms on the ccmputgr,use - 1. - Inspector: orly the tab key to move your Michael Kellett ^f cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name P.O. Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification �i 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority N?f J-Lj 12/04/09 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ! v O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Howland Lane Property Address Stephan Belfd Owner Owner's Name information is required for West Barnstable MA 02668 12/03/09 every page. City/Town state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 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. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M y 11 Howland Lane Property Address Stephan Belfd Owner Owner's Name information is reqpired for West Barnstable MA 02668 12/03/09 every page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Howland Lane Property Address Stephan Belft Owner Owner's Name information is required for West Barnstable MA 02668 12/03/09 every page. CityrFown State Zip Code . Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than 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. Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Howland Lane Property Address Stephan Belft Cwner Owner's Name information is West Barnstable MA 02668 12/03/09 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2004gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Howland Lane Property Address Stephan Belft Owner Owner's Name information is seguired for West Barnstable MA 02668 12/03/09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or'no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Howland Lane Property Address Stephan Belfit Owner Owner's Name information is required forWest Barnstable MA 02668 12/03/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of Date occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Howland Lane Property Address Stephan Belfit Owner Owner's Name information is West Barnstable MA 02668 12/03/09 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (f known) and source of information: 06/02/00 per BOH Were sewage odors detected when arriving at the site? ❑ Yes 0 No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Howland Lane Property Address Stephan Belft Owner Owner's Name information is required for West Barnstable MA 02668 12/03/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 4.1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3.6 p g feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gal Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 30" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Howland Lane Property Address Stephan Belfit Owner Owner's Name requir ation is West Barnstable MA 02668 12/03/09 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 11 Howland Lane Property Address Stephan Belfift Owner Owner's Name information is required for West Barnstable MA 02668 12/03/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cunt.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Howland Lane Property Address Stephan Belft Owner Owner's Name in°ormation is West Barnstable MA 02668 12/03/09 required fw every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number. 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/attemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The system has two five hundred gallon drywells in a 13'x25'field of stones.There was no sign of ponding or failure .The pits were dry. L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 11 Howland Lane Property Address Stephan Belfit Owner Owner's Name information is required for West Barnstable MA 02668 12/03/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt_) 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.): 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.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Howland Lane Property Address Stephan Belfd Cwner Owner's Name information is required for West Barnstable MA 02668 12/03/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. i L b� Tq Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7M 11 Howland Lane Property Address Stephan Belft Owner Owner's Name information is West Barnstable MA 02668 12/03/09 required for every page. Cityrrown State Zip Code Date of Inspection .D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation_hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered to 10.0 feet and found no water. I adjusted to 9.0 feet. The bottom of the leaching is at 7.5 feet i C HIGH GROUND-WATER LEVEL COMPUTATION Date: Site Location: l l LGj V J_ Permit: Qua r K Owner: Phone: Contractor: ,` Phone: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. (depth is in feet below land surface) Date: L? 0 mm/dd/yy feet below Is STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well S;;w B) Water-level range zone STEP 3 Using monthly "Current Water Resources Conditions" determine current depth to water level for index well. 1 6, mm/yy STEP 4 Using Table of Potential Water Level Rise for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 26) determine water-level adjustment. 1 0 STEP 5 Estimate depth to high water by subtracting the C O water-level adjustment (STEP 4) from l 0 measured depth to water level at site (STEP 1). NOTE* Tables 1-9 "Potential Water-Level Rise" are attached as worksheets to this file. month) index well data: www.ca ecodcommission.or wells.html Y p 9/ VYe No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migooar bpotem Congtruction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. ///11� /,I Vd �,.U, l/Z3A fW5 Assessor's Map/Parcel .,• Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/W _ Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. c Desc ion of Soilk 1,L�1 }/P r � � �1 Nature of Repairs or Alterations(Answer when applicable) `j� Date last inspected: Agreement: The undersigned agrees to ensure the co struction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title the Environmental Code and mot to place the system in operation until a Certifi- cate of Compliance has been'ssded �s Bo d of Il Signed Date Application Approved by a Date Application Disapproved for the following reasons Permit No. Date IssuedCWITI r No 0 Fee THE COMMONWEALTH`OF MASSACHUSETTS Entered in rnputer: Yes PUBLIC HEALTH DIVISION.- TOWN;OF BARNSTABLE., MASSACHUSETTS n rication for iss�poo,ar �pgten 6ngtruction Permit s . Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel. o. Assessor'sMap/Parcel / ��D© ' /_L _.y d� n 9 ' !'Tv Q °i /uv Installer's Name,Address,and Tel.No. LL' Designer's Name,Address and Tel.No. S r3/Lo _ Gflw.i T�, Go.Type of Building: -7 Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder Other Type of Building No. of Persons Showers.( ) Cafeteria( ) Other Fixtures ' Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Descry ion of SOR t" rrv�-��- , I.CJt�t J"< 17V w►v i�U w LID LAJ h) Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the co struction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title the Environmental Code andrnot to place the system in operation until a Certifi- cate of Compliance has been ' ed B I o d of Signed Date Application Approved by ® Date V Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS. BARNSTABLE, MASSACHUSETTS Certificate of (Compliance t THIS IS TO CE Y t tithe On-s' Sewage D' osal Sys m Constructed( )Repaired (Upgraded( ) Abandon )bv r at has ee constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated i Installer r Designer /-F\ ;� 0 f d/ i. !! The issuance of this permit sh 111r not e coffin.trued as a guarantee that the sy to w/Pl function as designedt Date �� mot. / 1 Inspector t //U� �/I� �✓ 6 --------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS mi5pooal p9tem Conotruction Permit Permission is hereby graytgd to Clopstrltctti( )Re air )Upgrade/�-- )Abandon System located at l �7U(il�i /2 Q qJ Y9-d _ and as described in the above A plication for Disposal System Construction Permit.The applicant recognizes his/her duty to compl' with Title 5 and the following local provisions or special conditions. Provided:Constructio must b completed within three years of the date of this p t. Date: Approved by l �0�61/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT WITHOUT DESIGNED PLANS hereby certify that the application for disposal works 5 con ction permit signed by me dated 1�--�� , concerning the property located at �� /A 6,4 P4 d/ 41111• / n/J t 44 meets all of the following criteria: /� • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling.. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. A • There are no wetlands within 100 feet of the proposed septic system I • There are no private wells within 150 feet of the proposed septic system VIV • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. /V v • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] ' • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W.Adjustment. _ DIFFERENCE BETWEEN A and B SIGNED : / "`'/ DATE: [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert vi \ - ...- -- ---------- TOWN OF BARNSTABLE LOCATION 11 HOWLAND LANE 2000-301 SEWAGE # WEST BARNSTABLE VILLAGE ASSESSOR'S MAP & LOT#4 INSTALLER'S NAME & PHONE NO. E L L I S BROTHERS C O N S T . C O . 362-6237 SEPTIC TANK.CAPACITY Soo LEACHING "" / �FACILITY:(type) 3 (5 0 �'} f-1�:;F (size) j2 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER O OWNER t�f — DATE PERMIT ISSUED: loo i j DATE COMPLIANCE ISSUED• tA 00 VARIANCE GRANTED: Yes Na rx % c i i 0 __ _€