Loading...
HomeMy WebLinkAbout0035 LOTHROP'S LANE - Health 35 Lothrop's Lane 109-005.006 West Barnstable i 6 a a s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments mY 35 Lothrop's Lane Olt GSM as Property Address " James& Kelly Smith ' Owner Owner's Name information is required for every West Barnstable r/ Ma. 02668 May 4, 2017 r page; Cityfrown 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. General Information filling out forms V I a on the computer, use only the tab 1. Inspector: key to move your cursor-do not Thomas Roux use the return Name of Inspector key. �V Company Name 89 Mayflower Lane Company Address East Wareham Ma. 02538 Cityrrown State Zip Code 774-678-9066 S14531 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is required for every west Barnstable Ma. 02668 May 4, 2017 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is west Barnstable Ma. 02668 May 4, 2017 required for every Y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Dorm Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 May 4, 2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 May 4, 2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. I For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. . 02668 May 4 2017 required for every y page. City(rown 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)] i D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 658 gpd t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 May 4, 2017 page. City(rown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter reacings, if available(last 2 years usage (gpd)): Detail: j Sump pump? ❑ Yes 2 No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Lothrop's Lane Property Address James & Kelly Smith Owner Owner's Name information is r equired for every West Barnstable Ma. 02668 May 4, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? I 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) ❑ Vnnovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 May 4, 2017 required for every page. City/Town State Zip Code Date of Inspection D. System.Information (cont.) Approximate age of all components, date installed (if known)and source of information: 30 years, Design plan dated 10/22/87. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 p g feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +100' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5' 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: 10.51 x 5.67'W x 5.67'H Sludge depth: 1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P Y wM 35 Lothrop's Lane Property Address James & Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 May 4, 2017 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 23" 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 24" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The outlet baffle has been replaced with a SIGH 40 PVC tee. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Lothrop's Lane Property Address James & Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma.. 02668 May 4, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Titles Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 35 Lothrop's Lane Property Address James & Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 May 4, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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 has been replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Both pit structures were dug up and inspected. The structural integrity of both structures was good. Pit# 1 had 30"of water in it at the time of inspection. Pit#2 was completely dessicated. The SAS is in good condition and has more than enough available capacity. See as-built for Pit designation. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 35 Lothrop's Lane Property Address James & Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 May 4, 2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number:p ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Both pit structures were dug up and inspected. The structural integrity of both structures was good. Pit# 1 had 30"of water in it at the time of inspection. Pit#2 was completely dessicated. The SAS is in good condition and has more than enough available capacity. See as-built for Pit designation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 May 4, 2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Am& Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 35 Lothro 's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 May 4, 2017 required for every - own State Zip Code Date of Inspection page_ Cloy D. System Information (cost.) 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 2 t C JA 1 1 000 74 'f i s t � - IA = :q �r��iiR rs NT Z F_ o .z ec, r C c t i #2 ro S- t5ins.3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Lothrop's Lane p Property Address James& Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 May 4, 2017 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: below 12' 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: 10/22/87Date ❑ 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: From the design plan on file. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection .dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 May 4, 2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ,r r f � t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17. Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Lothrop's Lane Property Address $ James & Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 April 30, 2017 ' page. Cityrrown State Zip Code Date of InspectionIND CAI Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. filling out forms A. General Information filling out forms 7—f— on the computer, use only the tab 1 Inspector: key to move your cursor-do not Thomas Roux use the return Name of Inspector key."�1f Company Name 89 Mayflower Lane Company Address East Wareham Ma. 02538 City/Town State Zip Code 774-678-9066 S14531 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 017 zz��— Aq:�-z Aoird ao Inspector's Signature f Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 Aril 30, 2017 required for every P page. City[Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by. the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owners Name information is west Barnstable Ma. 02668 April 30 2017 required for every p page. Citylfown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): The Distribution box is severely corroded, and is in need of replacement. ❑ 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): i ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Onspecti®n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 April 30, 2017 required for every p page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments GSM 35 Lothrop's Lane - Property Address James& Kelly Smith Owner owner's Name information is West Barnstable Ma. 02668 April 30 2017 required for every p , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either yes"or no to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM , 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 Aril 30, 2017 required for every P page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® . ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? i ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 658 gpd t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 Aril 30 2017 required for every P page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official lnspecti®n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 required for every April 30, 2017 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information • Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity*pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments uM 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 Aril 30, 2017 required for every P page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 30 years, Design plan dated 10/22/87. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +100'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5' 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: 10.51x5.67'Wx5.67'H Sludge depth: 1" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Mspecti®n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 Aril 30, 2017 required for every P page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 23 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 24" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The outlet baffle is broken and will be replaced with a SCH 40 PVC tee. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Lothrop's Lane Property Address James& Kelly Smith Owner owner's Name information is West Barnstable Ma. 02668 April 30, 2017 required for every P page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: I ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumpiing: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 Aril 30 2017 required for every P page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 11 Depth of liquid level above outlet invert 0 Comments note if box is level and distribution to outlets equal, an evidence of solidcarryover, n s a ( q Y Y evidence of leakage into or out of box, etc.): The Distribution box is severely corroded, and is in need of replacement. The D-Box will be replaced. Pump Chamber(Ilocate on site plan): Pumps in working order: ❑ Yes . ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Both pit structures were dug up and inspected. The structural integrity of both structures was good. Pit# 1 had 30"of water in it at the time of inspection. Pit#2 was completely dessicated. The SAS is in good condition and has more than enough available capacity. See as-built for Pit designation. If . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forums Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is required for every West Barnstable Ma. 02668 April 30, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Both pit structures were dug up and inspected. The structural integrity of both structures was good. Pit# 1 had 30"of water in it at the time of inspection. Pit#2 was completely dessicated. The SAS is in good condition and has more than enough available capacity. See as-built for Pit designation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 Aril 30, 2017 required for every P page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) s. Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: I Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is west Barnstable Ma. 02668 April 30 2017 required for every p page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 2 sf�ll 1 � r � Tk Noose -1—j—A 000 Ie � S.T. ou$lef j o r iA / 3 Afo to S- T ov -� = /7. S d Ito �� IBox . as ' TO fD l / C 2 t -3 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments GSM 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is West Barnstable Ma. 02668 April 30 2017 required for every P , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: below 12' 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: 10/22/87 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: From the design plan on file. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Lothrop's Lane Property Address James& Kelly Smith Owner Owner's Name information is west Barnstable Ma. 02668 April 30, 2017 required for every P page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ® 9 P Y P9 P i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I r Page: 1 CERTIFICATE OF ANAL PSIS rf" Barnstable County Health Laboratory Report Prepared For: Report Dated: 10/24/2002 Order Number: G0217876 James D. Smith 35 Lothrops Lane West Barnstable, MA 02668 RECEeVED Laboratory ID#: 0217876-01 Description: Water-Drinldng Water OCT2 8 2002 Sample#: 17876 Sampling Location: 35 Lothrops Lane,West Barnstab a l� Collected: 10/22/2002 Collected by: James D.Smit 109-005-006 TOWN OF BAP",'STA E. 1d: 10/22/2002 HEAUF DEPT. .Routine " ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 1.7 mg/L 10 EPA 300.0 10/23/2002 LAB:Metals Copper <0.1 mg/L 1.3 SM 3111B 10/23/2002 Iron <0.1 mg/L 0.3 SM 3111B 10/23/2002 Sodium 14 mg/L 20 SM 3111B 10/23/2002 LAB: Microbiology Total Coliform Absent P/A Absent 309 10/22/2002 LAB: Physical Chemistry Conductance 123 umohs/cm EPA 120.1 10/22/2002 pH 6.4 pH-units EPA 150.1 10/22/2002 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. i Approved By: G. (Lab Director) (o�t y�zaoZ .-::- ..• .c:'-�is ,, •,',.e=,. ' Superior Court Rouse, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I r � P COMMONWEALTH OF MASSACHUSE'l."1'S P=CEIVED EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS' s DEPARTMENT OF ENVIRONMENTAL PRO ECTION = OCT 3 12002 W ; ' d TOWN OF BARNSTABLE HEALTH DEPT. eW t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION f�11 rr,,V Property Address: 35 LOTHROP'S LANE W. BARNSTABLE, MA 02668 10q V so C)U- Owner's Name: ROBERT WASHEK Owner's Address: 35 LOTHROP'S LANE W. BARNSTABLE, MA 02668 Date of Inspection: 10/21/02 Name of Inspector: (please print) JOHN GRACI0 Company Name: . SEPTIiC INSPECTIONS im ' CO§,V Mailing Address: "' 'IP.O.BMX 2119 TEATICKET,MA. 02536 Telephone Number: 508-564-6813`FAX 508-564-7270 CERTIFICATION STATEMENT I certify that 1 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 cf-.he 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: a X Passes _ Conditionally P :yes _ Needs Furthe valuation by the Local Approving Author ity Fails Inspector's Signature: ;' __ Date: 10/11/02 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe ion. If wt a 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 t')the'buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. t ****This report only describes conditicits at the time of inspection and under the conditions of use at that time.This inspection does not address how the syst!er7 will perform in the future under Ilse same or different conditions of use. Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A L CERTIFICATION (continued) Property Address: 35 LOTHROP'S LANE W. BARNSTABLE, MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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. } 1, Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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 rep lacementpor��gpair,as approved by the Board of Health,will pass. Answer yes, no or not determined(YN,ND) in the for the following statements. If"not determined"please explain. n/a 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. j ND explain: n/a 1.1 n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled.or'uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: n/a -e n/a 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'pi`pe(s)are replaced _obstruction is removed ND explain: n/a ,•f. Page 3 of I 4 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 35 LOTHROP_.S LANE;W. BARNSTABLE,MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 t, C. Further Evaluation is Required by the.Board of Health: _ Conditions exist which require fu;tl er evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the eny<ironment: 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'wtii6 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 septicl.ttaokand soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to asurface 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 tdnk 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 n/a "This system passes if the welLwater analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached`to this form. 4 . s 3. Other: n/a :Li i.,t7 ,1 • t 4, i Page 4 of 1 t ,r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 35 LOTHROP'.'S.LANE W. BARNSTABLE,MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"t6'e:ach of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool r and or surface waters due to an overloaded or clogged n '`of effluent to the surface of the o _ X Discharge or ponds g g SAS or cesspool " X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth i _ X n cessp ool is less than 6"below invert or available volume is less than 'h day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ONE YEAR BY OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspo°ol''o`r rivy`is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspo6`.l;or'pri,vy is.within a Zone I of a public well. X Any portion of a cesspool or`privy is within 50 feet of a private water supply well. X 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.,yliform.bacteria and volatile organic compounds indicates that the well is free from pollution from that'facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or other failure criteria are triggered.less than 5 ppm, provided that no o A copy of the analysis must be attached to this forma (Yes/No)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 systerri;fails. Tile system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: j To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: The following criteria apply to large'systems in addition to the criteria above) ( g pp Y , yes no _ X the system is within 400,feet,of a,surface drinking water supply X the system is within 200 felt of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water w, ell w`t. I li' •�. If you have answered"yes,'4°t6 any,question in Section E the system is considered a significant threat,or answered "yes" in Section D above the II►rge:VAC1)1 1il9 I'll iled:T'he owner 01.operator 0f any large System c0119itleaed signifiFant 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. Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 35 LOTHROP'S LANE W. BARNSTABLE,MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No X _ Pumping information was l!-rovided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks r. X _ Has the system received norinal flows in the previous two week period? X Have large volumes of water.been introduced to the system recently or as part of this inspection '? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelfing"inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ 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'? X _ 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: Yes no }, , X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] t y ` 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 35 LOTHROP-S LANE W. BARNSTABLE,MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 ' Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.20.?-(:for example: 1 10 gpd x#of bedrooms): 440 Number of current residents: 4 Does residence have a garbage grinder(yes or'no): NO Is laundry on a separate sewage system(yes'or no): NO [if yes separate inspection required] Laundry system inspected(yes`or no): NG' Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR;15.2Q): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a J. GENERAL INFORMATION I Pumping Records Source of information: ONE YEAR BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/a gallons--How vvas quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system (yes or no)(if yes,attach previous inspection records, if any) _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'DE1= approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1989 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO i ' 6 Page 7 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 LOTHROP'S LANE W. BARNSTABLE, MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 BUILDING SEWER(locate on site plan) Depth below grade: 18" ; Materials of construction:_cast iron X40 PVC t; other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): WELL WATER SEPTIC TANK: X locate on site plan) S ( p ) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explairi)n!a If tank is metal list age: n/a Is age corifirimed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1500 GALLONS" 1. , Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scumlto bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING'EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_iberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet ice or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.) n/a 7 Page 8 of 1 I z. , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 LOTHROP'S LANE.W. BARNSTABLE,MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) t Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons t` Design Flow: n/a gallons/day Alarm present(yes or no):.N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and:float switches,etc.): n/a DISTRIBUTION BOX: X(if,pres(ntr.must be'opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribatio'n'lto outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SU1�D. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no):INTO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 1 I OFFICIAL INSPECTIONt FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 LOTHROP'S LANE W. BARNSTABLE,MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 n site Ian excavation not required) locate o s q ) SOIL ABSORPTION SYSTEM (SAS): X ( p If SAS not located explain why: n/a Type 1000 GAL 6' X 6' �. leaching pits, number: 2 leaching ch ambers, number: n/a n/a 9 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a t';;innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,lsigns of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. DID NOT EXPOSE ONE PIT. OTHER PIT WAS HALF FULL AT TIME OF INSPECTION. STAIN i LINES INDICATE OTHER PIT HAS NEVER BEEN MORE THAN HALF FULL. BOTTOM IS AT 10 FT. CESSPOOLS: (cesspool must be pumped a§ipart of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil„signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a t4 4 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 LOTHROP'S LANE W. BARNSTABLE, MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 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. AG a 0 i 6 AA q0 PqA Zvi Pia 51� l3C 3� Z 3 CE �)Z p6 3 PO 37 V in Y Page 1 I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS y, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 LOTHROP'S LANE W. BARNSTABLE,MA 02668 Owner: ROBERT WASHEK Date of Inspection: 10/21/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet . Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excava'tors,.installers-(attach documentation) NO Accessed USGS database-e,,plain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. tr 6 r ' F d ` rf�� TOWN Oki BARNSTABLE 4iI d ll(,� LOCATION 4'ag Al, SEWAGE VILLAGE JbJ'ARaoa ASSESSOR'S MAP & LOT INSTALLER'S NAME &.PHONE NO. Caa ,-3/76i SEPTIC TANK CAPACITY Ia®0' LEACHING FACILITY:(type) 6Aw& (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER �jQ�11f BUILDER OR OWNER DATE PERMIT ISSUED: , DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ` � 1 s. �� ir„"` �� .S�,6eJ � � �/, �p _ � 36y � s� r V 0 C)j No.? / f,-7 Fps. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _o Gu...4"!,.................OF.........../:..' .r.h•.. '� ---1 Apli irFation for Diiipnaaal Works Tonotrnrtiun Frrmit Application is hereby made for a Permit to Construct (X or Repair ( ) an Individual Sewage Disposal system at.. Ag Loc t dd s or Lot No. c� °, --------••--•.--••----• Address a .................................. ---•--------........................•...... Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................... .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................. No. of persons............................ Showers O — Cafeteria ( ) a Other fixtures ............................... . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/Y.O.agallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area__P6 d_.__---sq. ft. Seepage Pit No----------_--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by-------------------------•-.......•----....-------•---------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.............._......... ri Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water______-._-_-___•••-____. 9 .................._......---•--•----•--------•------•--------------------.......--------------•............................................................. 0 Description of Soil..................................................................................................................----------------------------------------------------- V --•--•--•-•-•--•--•----•--•---------------•------•-•-------•---•--•=----------------••----••••--•-•----------------------------•-----------•---••••.................................................... W ..............._.----------•-•--•----••-------•-----------•-------••---•--••------••---•----•---------- -----------------------•--- UNature of Repairs or Alterations=Answer when applicable------- _ __ . ... .............. i ------- - ----------- - Agreement: The undersigned agrees to :install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Ti T 5 of the State Sanitary Code— The unde sigodther agrees not to place the system in operation until a Certificate of Compliance has be issued by t and igned••---- ------- - ---••. . ---- -- ........................................ • Da Application Approved By--- - ? .. . .. . .............. .. ..........••...............---........ �� 7------ Date Application Disapproved for the following reasons-------------------------------------•---------------------------------------•-----------------------------•----- •--------------------------------------------------------•------------------------...........----------------.._....------•---•---•--•---•--•--•----•--------------------•-----••-----......-••-------•- 97-336' Permit No. Date ----•----•-------- Issued---•------------------------------------•---------...--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE LTHDE I N G ENGINEER MUST SUPERVISE ` nn rr t TION-AND CERTIFY IN WRITING ........... LV-.........OF........T,. ... .. . .... = -,A••W-JAS INSTALLED IN STRICT (9rdifirtttr of Tompliairr P1 AN THIS IS TO CERT Y Tat the d* i u 1 ewage Disposal System constructed X or Repaired ( ) by ........................................ ................................. at f,.�. It, ... ,taller •--� 6., Z-16 has been installed in accordance with the provisions of TILT-LE 5 of T State Sanitary Co a r►ijed in the application for Disposal Works Construction Permit No.__ --�3 __..•.__ dated_-� _ ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ inspector.................................................................................... 0 C)'5 0",-2 No .7 .7!.� -_.. / ,< Fmcll .............. THE COMMONWEALTH OF MASSACHUSETTS ` BOAR® OBE HEALTH ...... ..............OF.......... ...... r=--- .. �.----........ Apphratiun for Uiuposal Works Tonstrnrtion Prrmit Application is hereby made for a Permit to Construct ( X) or- Repair ( ) an Individual Sewage Disposal System at: .. t at• .0............wiz4zo---------.. ---------------------••-_•__-__-__-•-•--•- Lo d r o ..........-------------------------•-•---.. . ...n - Address a01 / �°J -•-•-------------•--------- ..........-------------••-----• --•---•--------•--........--------•---•---- Installer Address Type of Building r Size Lot----------------------------Sq. feet Dwelling—No. of Bedroom s.__.........I/..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures --------------------------•--------------•------...----••-•-••-•-----••---------•-•----.-•--•--••-•--•---.....-•----••-••-•-•-•--•---•---••••..-•-•-- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacityg.0�1.gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—Nlo. .................... Width.................... Total Length.................... Total leaching area_kk2 -------sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area....._............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................._.. Date.................................... 04 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-•••--••....................•-•-•••.............---••••-•-••-••-••......._..---•---_•••••-•••_•••--........------•••-•••••---•..._...........---------.••••. 0 Description of Soil....................................................................................................................................................................... x W ...................•--- -----------•-----•--•••--•--•-••••-•---•••-•••••---•-......---•...............•--••-•-•---. x Nature of Re airs or Alterations—Answer when a hcable..............C.-_� t '.__.. __.__.<< U P PP • � ------------ ..........................................................................................................................................(I.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of imi ^ of the State Sanitary Code— The u ersi urti:er agrees not to place the system in operation until a Certificate of Compliance has is ued by boar ' ea t "— igned••.......................-----.......................................----•••- �j D � Application Approved By..B_—....... ..i.....+'..;�.il.1 I n...-• ---•--.......... -- Date Application Disapproved for the following reasons:-•-•---••-----•-------------------------•--------•-----••-----•-------•--•----------------_----------------- --•-•-•-•--•--••----•-•---•----------••••••••••---•-----••-•-••--•-•-•-•-•...-•---•..................•--•---...._..•--••....-----•......--•••---•-••......•--.......................................... Q Date Permit No.....!?.�- Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HjyE,ALT� ...................V.....1.`!............OF......�,,,� it J/.'f .l..r.:.. ................... _I Trrtif irtt#r of Tu plianrr THIS IS TO CERT at thndw'd -Sewage . isposal System constructed ( ) or Repaired ( ) / Ij j at 1-.-}---- 5 ------ ,stall.. ----�rr!j � f has been installed in accordance with the provisions of Ti poi T�j State Sanitary Co / ed in the application for Disposal Works Construction Permit No._ ......... dated_/1-__- ,(� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector...................•-•--------------••----••-------------------•••-•_----•--•-•----- THE COMMONWEALTH OF MASSACHUSETTS QAR` F HE ,4LTH � � r ... Y V N 1�'O.a�..r�..-_.f7�,..1_----6 FEE.. ...--••---••---.....� Disposal Works• orku� � no#r ionf rrntt� Permission hereby granted------..... ' � ._.. ...•- .... to Construct) or/ R^epa- ( an In ividu 1 ew ge s S st at No S.eet ��� �. as shown on the application for Disposal Works Construction Permit NoL.S_ ______________ Dated..__l _ n ••----....--•-•=-------••••-.... S::)-----------------------_----_--••-----•-.- of Health DATE i FORM 125S HOBBS & WARREN. INC.. PUBLISHERS 1 I,I u Department of Eovironmental Management/Division of Water Resources � WATER WELL COMPLETION REPORT WELL LOCATION Address / O f // (- r r City/Town ll). /-."r I P G.S.Quadrangle Map Grid Location r / Owner-I-)PA-ox 4,-1 A,)\Pa j Address G �,17 �•• "'Yi-in H 1,;1 r 1, WELL USE CONSOLIDATED WELL Domestic � � Public ❑ Industrial ❑ Type of Water-bearing Rock Other Water-bearing Zones Method Drilled go`//Tar U 1) From To ? c� 2) From To Date Drilled - c?, - �S 3) From To 4) From To CASING Depth to Bedrock Length C>� ! Diameter. f Type I I�.d,,: 4/C. UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials Feet below land surface �� Sand: fine❑ medium Vcoarse V Date measured //�'d - , 1,7 Gravel: fine❑ medium❑ coarse❑ GRAVEL PACK WELL Screen: Slot# /C�lengthy_from to Yes ❑ No Y Split Screen (or 2nd screen) WATER QUALITY TESTS.MADE Slot# length from to Chemical ! Biological ❑ Depth To Bedrock PUMP TEST / Drawdown feet after pumping days 6 hours at (7;)(-) GPM. How measured 7 or- on•/1 Recovery feet after hours. w- p LOG of FORMATIONS COMMENTS: (On well or water) Materials From To 0 DRILLER Mop � lb r- Firm II1��1 /�� �,1�2 I(��•�y/../Yi I�/11 S _ C Y..J .. ,fA/,lX !J C.I •���k� 1�� Address ` City i::o rc s-tc-Lr I P Registration No. )`A Aerator s ignature Please print irm y BOARD OF HEALTH COPY 25M 10-85-807101 �s:{r:ssssssssssr.:sss:s{s..... s:s:s::si:s s:rssssss:s:::ss•.:ss:ss:sss{ {{:{{s ss :s:s:sssssssss s s{s{......: :r{sssss:s:sr;::s s r{ss•.:s{s{:s:rsssss {ssnsr:ssss s s ss:sss:SssSsssS::s:srsSs{S{s{FS S ssSfSssssr, yet;,;,,,,,,,, ;, ;::::::..,,,,,,5„:,:,:::::5:: ,,::,:::,:::::::,::,:,,,f.,:,:,::.....,T,:SttS:::::::,:,,,,SSS:S:F.:.:::...,SS,:.S,,:,,•,,::�:,,5 SS,.S:, n?iS?????:S l?l?1,F;:????,?.n?.?F ..,.. i. ,.F. ............ . ....( . .. .... :..., :.:.i ...::.,i,..S ..,, .......,.i, .... .. t't ...... ........ F.1:1? ... f ENVIR®TECI i lLABORAT0RgF_,S - 449 Rte. 130• Sandwich,MA 02563• (617) 888-6460 » CLIENT: Peter Hawley R E LOCATION: Lot 11 Cedar Street ADDRESS: Box 317 W. Barnstable,MA - E. San wich,MA 02537 =» COLLECTED BY: Meehan Well SAMPLE DATE: 10/26/87 TIME: 9:00 AM DATE RECEIVED: 10/26/87 SAMPLE ID: E 684 JOB #: New Well WELL DEPTH: 180 ft RESULTS OF ANALYSIS: Parameter Units Recommended limit Result - Coliform bacteria/100 ml (MF Method) 0 0 .4 pH pH units 6.0-8.5 6.42 » Conductance umhos/cm 500 108 x Sodium mg/L 20.0 10.2 Nitrate-N mg/L 10.0 .09 » Iron mg/L 0.3 <.05 Manganese mg/L 0.05 Hardness mg/L as CaCO 3 500 Sulfate mg/L 250 �x Potassium mg/L 20.0 Alkalinity mg/L 200 -" Chloride mg/L 250 - » COMMENT: _ YES NO ❑ WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TES D DATE C� Z `+.##iii#iss#:::su:#:us#t##Eisasts#s:s::s:::sss:ss#:s:siiiiii:::sssss::ss:::ss::::t:uss:s#tsss:uussisss#ts::::stt:ssutttssstssisttsts:t:t#s#s::tssstts:u::::ist:#s:tssuss:tssstt:tt###:ftstssu::s:u::#tsts#iii:::##si###:##ii##i#ii#11'+�`' i SMI / K LLY RESID NC 35 LOTHROP'S LANE W. BARNSTABLE, MASSACHUSETTS Dv�; 7 OWNERS: JIM SMITH & KATE KELLY3 35 LOTHROP'S LANE W/ BARNSTABLE MA 02668 ARCHITECT: 1313 JAMES D. SMITH, A.I.A. NEW ENGLAND DESIGN P.O: BOX 311 W. BARNSTABLE, MA 02668 TEL: (508) 737-9295 DRAWING INDEX: T1 TITLE SHEET LI EXISTING SITE PLAN L2 PROPOSED SITE PLAN - Al NORTH & WEST ELEVATIONS A2 SOUTH & EAST ELEVATIONS 0 O A3 FIRST FLOOR PLAN A4 SECOND & THIRD FLOOR PLAN A5 BASEMENT PLAN A6 FOUNDATION PLAN A7 SECTIONS �C A8 FRAMING PLAN SHEET NUMBERS A9 FRAMING PLANS Tl FILE NAME, 7FJOF SK Tl 1 LOTHROPIS LANE s J 3 �N1 11 0 SE,N0,35 A00 3 Q 3 �n r- M � � o � o cV ® *04 N � � f1mTY5 TIDI fliY11ERS f� I MTN mmu DWELLIINNG UAM V MM LAWN MFn NEV ADDITION NEV DECK 2q2�0 a , N / y SHEET NUMBER, 16' SCALE 1'=20,11 MA FILE NAME, ?HOF SKT= L=21 N 27°55�0' W 252,00' mIn I'll mr a um 3Eti161 g, ammin I � _ I I � i �►u�om�s>o�wlr I mm Iug=WILL FI M LAW WA Am Lu �v gac ! o o o MM IAAI WA L-------� 2429� WW FUME EV PROPOSED SITE PLAN .����� � 4I SHEET NUMBER, 22,6 SCALE 1'=204, [M15 ,x ALE NAMES SK L2 !'i P" &w ` „��,,• ram,r��;�'�T.� ! e9 D. � - our lo'-o Irrs(mcwnNs) ati+r W. 6 ' --------- -------------------------- --------------------------- FIANTIN D[D NR4 W(X)D WAIL UNDER FENCE yp ■, `p�F N FENCE j ^`—,,/■11 .'�a� l•1 F N DN. ' I I I I � ou�unoR I I j L J NEW STOW[STAIRS I 2 ECK RWF UN[BELOW � O DECK >g O a 9 I a O EATING AREA KITCHEN 1 mAUNDRY/ 10 MUDROOM I I �' O FILI.IN OR FRAM[FOR FOR FUTURP.5'-O"C.O. I I 11 2G'-O'TO FRONT F ABove r—� J ——— I '� uWe of exlsTwG House. L—J BUILT- TN Iv 5KYUGHT I 3-O' ® Q `� I DN. R L---L� i �.. O FAMILY I EXIsnNG) RCI OOM O O O (EXISTING) NEW PHONE O PEA- REF. O CL ❑ CENTER - DN.® b ' c ABovE FORMAL f DINING LIVING p $ ROOM DP FOYER ROOM lie D (EXISTING) (EXISTING) (EXISTING) . LL LI 0 } 0 F O W WINDOW SCHEDULE U KCY OTY. D6CRIPTION ROUGH OPENING MANUPAGTURCR/MOD[I. Z A 32 DODULC-HUNG 2'-G-z.4'- ±M5PNG ANDERSEN WOODWGIIT WDH 2446 W W S� B 6 DOUBLE-HUNG 2'-G I/B'.3'-47/B' AND[R5EN%000PIGHT WD11 2432 V/ z f. C 2 ORQC TOP 2'-G'.2'-G' AND5t5[N TO MATCH WOODRIGHT 2446 LU AN FI RST F LOOP, PLAN DI CIRC E TOP TO SIT ABOVE(2)2446 WSTUD POCKET 2 244 VKX]DR GHTS W UD POCKET A/ W SCAIf.:1/4'=I'-Gf ML,� DOOR SCHEDULE W Ix U) KEY OTY. Ur.S RIPTION ROUGH OPENING MFRJMOUEI. NEW 3068 6-PANEL METAL ENTRY DOOR"12-SIOPN[J \O Q I I FRONT DOOR W/51OEUTFS 3'-O.G'-I9x GRILLES TO MATCH AN PERSON WOODRIGIIT WINOON`.a' 2 m REFURBISH EXISTING EXTERIOR FRAME F FIRST FLOOR ROOM FINISH SCHEDULE 2 PAIREAR 066INTRY-29689U[ METAL INTMOKD S 1^ 3 3 PAIR 206E INTERIOR FRENCH IXX)RS 9•.9'J4'r 6'�• WOOD INTERIOR FRENCH TX1pR4 ROOM FI,OOR WADS WAINSCOT TRIM NOT[550OPC OF WORK 4 - 2666 4-PAN[I-INTERIOR DOOR 5MD MASOND[ (n S FORMAL UVING WOOD PAIM YES SHCFFICUJ EASING 5 24GG 4-PAN[I.INTERIOR DOOR S D MASONITE DINING WOOD PALM YE5 EXIST.G.G.WRNIC[.MOWINGS 6 2 20GG SOUP MA50NITE 2-PANEL SWD MASOND[ VM[Re APPIKAB FOYER WOOD PAINT NO EXIST.CLG.CORNICE MOLDINGS 7 1666 SODIJ M0.50NIT[2-PANO. 5IX1D MASONIi[ wn APPucAB MIST. .CORN, S NUMnEp I FMILY WOOD PAINT YES WHC . b 5OG650UDMASONITfUI-FOU SWDMASOND[ EATING WOOD PAINT YE5 EXIST.0 G.CORNICE MOLDINGS 5mG FRF.NCFIWOOU GUTTING PATIO DR WHPR[APPIJCAB 9 KUCHEN WOOD PINT NO EXIST.CLG.CORNICE MOLDINGS I O I W}{Dj[ARp.L—p 30681NSUTATEO MRAI.9 UTf WINDRY WOOD FAINT NO EXIST.LUi.CORNIQ MOLDING£ I 1 2 90700VCRHCAO Yfn[RE PPPLICAB FIRST5CCOND FLR STAIR WOOD PAM NO U15T.CLG.CORNICE MOLDINGS I2 2666 INTERIOR FRENCH IX)OR FILE NAMEI -y SKA3 1 44 • 36'ff 7'-C JPAIJ��WICMTrR OF WINDOW'DELOW I.INC OP ROOF UCLM O a �a Ld Nrw �ADove m �A:uzz1 TOImr F �\`J—J/ �9 b / b (OPEN TO 9EIOW)NEW L NEW MASTER vA"" oee"ADov" m BATH O — g POST NBREMOVE U15TINGIwo WWDPOST------- BATH 14 ING LEX1ISN[W WALK-IN 5 ANNyG R' BEDROOM CIOSET (IXISTING) IX1555Oj UN. UOOR S`v17HALL �Ro � UP (U(15TING) O wBfOT� 1 �l (EXISTING) (D05TING) 2 �'-� A rI_ UI:5TING N. Ow6��C1 iyQP C5TINGDOORTING5TING IXSTINGQCI UMASTERCHELSEA'SBEDROOMBEDROOM ISTING? (D(15TING) Q a� SECOND FLOOR PLAN THIRD FLOOR PLAN 5CAIL:1/4.=P-C 5CAIL: 14' SECOND FLOOR ROOM FINISH SCHEDULE ROOM FLOOR WALLS WAN500T TRIM NO(E5/5COPC OF WORK 5C OW ROOK NAIL WOOD PAW No ("ME APPIICFD I.)I MASTER BEDROOM WOOD PAW YE5 C%15T.Q.G.CORNICE MOLDINGS CRC APRICASI CNEL5 s ROOM Wppp PAW NO C%15T.QG.CORNICE MOLUING5 U ERE APPI ICAD I.IXI'5 ROOM WOOD PAW NO C%I5T..GG.ECOAPRMIQ MOIDINGS MASTER DATN WOOD PAW vE5 IX15T.CLG.CORNIQ MIXDINGS P.RE APPLICAD Q W U(15T.Q G.CORNICE MOLDINGS DATN WOOD PAW NO NMERCA"'CAB FIR5T5ECOND FlR5TAR WOOD PAW NO C%15T.Q.G.C-, MOLDINGS N THIRD POOR STAR WOOD PAW NO W W � NJ m W m N Z 0Q m °4 NM3 D. 3 v SHEET NUMBERI I'ro ;3• TNT ' FILE NAME( SKA4 I.s f! no 3G1±(TO EXI5TING DROP IN FOUNDATION WAD) 2100 Co Or loam TO or TANG 15TING 5EPTIC _ `vL TANK �lVl X d I ma w � ----- '` NEW STONE STAIRS g{ 9 J ��a �LL7V CRAWL 5PACE FULL HEIGHT —� 5TORAGE n O I I I I I 1 O O FRONT LINE OP HTR. it LINE OF!Y15TING MOOS[. no UTILITY ROOM UP4• � I NEW 31/21B lPILY LOWM C H I LD RE N15 ON 30.317.12•FDOTI TV ROOM UNRCINFORCCD III ' 7 NCWWI2x 2G NEW 3 I/2'm AL COLUMN W/2. N'D' II I r UN 30'x 30'x I 'FOOTING zZ [%15TING.COWMN COLUV[IX15TING O WW UJ Q UMN EXIST. 4 HALL(IXISTING) IXISTING W I. ____ EXI5TING TOOL REM ED N11 GARAGE jrI � IXISTING U OSR III HTR __= I EXIST. II 9yO(Cu UP U15TING 51- NEW I AB j{ ` C%I STINGGOSCT w S a� 11 I IX15T. FXI5T. II b I NY4 FULL-N[IGMT _ BRAINING WALL �UNC Uf PORCH ABOVE FI[U)STON[RETAINING WALL I es-o'�crott►n Nam+ W U Z BASEMENT FLOOR PLAN W W < W � �j ir N BASEMENT FINISH SCHEDULE ROOM FIWR WALLS WAIN5CCi TNM NOf[5/SCOPE OF WORK BASMCNT 5TaR WOOD PAINT EXISTING 'Wry gppLlCpp 1 W � BASEMP.NT HAII. Tllf. PAINT EXI5TING PXIST.C.G.CORNICE.M(NDINGS Z WrtC C APPLICAB DASCMENT CLOSET TILL PAINT NO IX15T.LLG.CORNIC[MOLDINGS WNCRC AFFLICABI THIRD FLOOR STAIR WOOD PLANT NO EXIST.LLG.CORNICE MU ,.- O m .,�,• W M 3 SHEET NUMBER, FILE NAME, OF SKA5 5 i SOIL L 0 6 NO. 1 'z- '� NO. 1 SITE PLAN �I 1 _ -CD � A � D S��- (o(a 1 ¢ 3 LDG-, A 5 ��r1 t7uVly �Ou 7AGT .ry n I 6 _ - �>3 4 (, r�Gg2A`) � _ BD � E-0 �! E F-tL A uv/0►7, aHU5TAR. = ;� ;i bZ TOP OF FOUNDATION EL.: 7&_._ -F- yOiN -D OF HEAc A-, •i -7.5 'EL • •� — 1 D F i u c �A►J4 � 0 dl t '' , - -1, • IN.EI L, (O r / � � . ry 11 r IN.EI.j'� sip , 2 COVER 1 1 3/1 WASHED STONE plc vtlY�rc - s�' 12 •. 0/A W/ i"SUMP IN El. ,. .: 3/4" 1,� 1/1 " WASHED STONE tE�L' 13 r 4' LIQUID LEVEL , ° ' ��' ' 14 ✓ � UEFF. DEPTH • is eo . PERC TEST RESULTS PRECAST SEPTIC TANK WITH - PRECAST LEACHING PITS PERC RATE : CAST IN PLACE INLET AND EL• .,4 J; - 4' F WHITNESSEO BY: ,�'�. ��'�.'� _2tA, • ' • NO.: OUTLET T 'S PER TITLE Y �r _ _ '^'ram k ��` BOARD OF HEALTH S _ 2 v 5TN)6 ,/ _ ? E�1L, k)AT Ez c DATE: SIZE :E : 1 D b �� 4 �'- D I A r LL- A.�b),)dv 4 C- 0 I A . R Fo�� 1_0 T -'14 WF—L.L_ FL ten, h, �,�r `�''� A� 0 le PROFILE OF PROPOSED SEWAGE SYSTEM SYSTEM OES16NE0 BY THE TOWN OF QtJJ"= `-lk A`` op 4jv�` LI REGULATIONS AND STATE TITLE Y FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE . 1/40 a 1 0 . o (s0 wV/ N . B . t) 'It-ALL LWT \` 1. ALL PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE 2. ALL PIPES SHALL BE SLOPED 1/4"' PER FOOT EXCEPT FOR B'a= �5"0x -�- s01 90 THE FIRST 2 FEET OUT OF THE O / B WHICH SHALL BE LEVEL 3o ' i,�o 'r,> 3.. DESIGN FLOW 4 BEDROOMS �AT 110 GALOAY PER BR. 44o GAL/DAY -6-01 SEPTIC TANK SIZE 14 X ► �-06AL. iso �`�----- -- wE`1" CIO USE �� 6AL. W/ GARBAGE DISPOSAL _ or f; \� LEACNINi SYSTEM: USE �_ P,-L N �: A CH Pi � &' 00 M EFFECTIVE AREA: SIDE icy 471cc BOTTOM %}- �. ; �L �: 4 � � _ �78 � `� � ' k _ lD9BG �D \ OPEN TOTAL FLOW S4 - 3 SPACE TOTAL REQ'O FLOW 4 40 X 1, 0 = 440 W/Q&T GARBAGE DISPOSAL s 0 RESERVE FLOW ► D`)B -4gv se� 6AL/DAY T -� o Il, _.. _ Lip .... -•`.,_ - a, � _J/ b REFERENCE PLANS 12. ` 90 9D 85 90 G-07- 15 yY 5 44- 4d- 106 A4z•00 APPROVED BY ; _ o` " sP'°``E _ ROARO OF HEALTH - _ sG A OATS : ______ , PROPERTY4 OINNER : \// L - ' L c-`� SITE AND SEWAGE PLAN PAtiL .` Z �A A,,1`.� 1.A1!T`I-4 ( 'r BE 0 Rooms SI f441Z F00A►L4 Ch"SU 1 w G 1/fir tl C..G a , �o�'� -� ,E� -. 4 MIER THEW r't'.ts (�pT• J/ L G' iH r'� w r .ylv _ 1/1� K > �� ��/i t'>LE. - No. 32008 /ar ...,��r W ' 23 5 11MaE E%.1m v �. ALM