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HomeMy WebLinkAbout1492 MAIN ST./RTE 6A(W.BARN.) - Health 1492 MAIN ST. , W.BARNSTABLL A' = 197 048 p` 01P 19-1-0qf Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name / information is West Barnstable ✓ Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Brett Hickey 1 3 ST9-71 key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 1 374 Route 130 u� Company Address Sandwich Ma 02563 City/Town State Zip Code 508 477-0653 S113747 Telephone.Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑Q Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails :.DgadN igm Mares Haw Brett Hickey �: ��.a.r.o.W..reaa.ortre�nwm� .mFus 6-6-19 ...ate:2019 U9.0)09:1]:4 OCW Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. � rt5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18jt,)� y J c� Commonwealth of Massachusetts rn ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A v� Property Address Robert Gustafson Owner Owner's Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑i 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts �u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): P ( p ) ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 f Commonwealth of Massachusetts �s Title 5 official Inspection Form I� Subsurface Sewage Disposal System iForm -Not for Voluntary Assessments 1492 Main Street Route 6A u Property Address Robert Gustafson Owner Owners Name e information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A u Property Address Robert Gustafson Owner Owner's Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ❑ Q 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ a The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ Q Have large volumes of water been introduced to the system recently or as part of this inspection? O ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? ❑ 0 Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: El ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owners Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): 330/GPD DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes rol No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 91 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ® Yes ral No See below Water meter:eadings, if available (last 2 years usage(gpd)): Detail: 'WELL WATER' Sump pump? ❑ Yes N No Current Last date of occupancy: Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A u� Property Address Robert Gustafson Owner Owner's Name information is west Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Retail/office Type of Establishment: 90GPD Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 50GPD/1000SQFT Grease trap present? ❑ Yes 0 No Water treatment unit present? ❑ Yes 0 No If yes, discharges to: Industrial waste holding tank present? ❑ Yes [E No Non-sanitary waste discharged to the Title 5 system? ❑ Yes 0 No Well Water Water meter readings, if available: current Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- Last pumped 2 years ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts �M1 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. El Other(describe): Septic tank, pump chamber, d-box and SAS Approximate age of all components, date installed (if known)and source of information: 1999 per plans Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ❑® 40 PVC ❑other(explain): >100' from well to SAS Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts ` �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is west Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ■❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 500gallons 511 Sludge depth: 3119 Distance from top of sludge to bottom of outlet tee or baffle On Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is Test Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day l5insp.doc-rev.7/2 612 0 1 8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 cam, Commonwealth of Massachusetts 1= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is west Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): o" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 10. Pump Chamber locate on site plan): Pumps in working order: Yes ❑ No* Alarms in working order: a Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber, pump and alarm were tested and all in working order at time of inspection. If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (5)500 gallon chambers El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2U2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............ 1492 Main Street Route 6A u Property Address Robert Gustafson Owner Owner's Name information is west Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Chambers were dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert solids Depth of so Ids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is required for every West Barnstable Ma 02668 6-6-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 .. Commonwealth of Massachusetts , �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately u A) r)rr 6elz .. sEWACE 0, VUA.AGI d. 1y'f�h> m.��C' s.►aun�u li sEmc rANK c"Acmr EXACWNO FACTY.M. ttyve S� c- r ts:u).. _ �7 "'`"""'...."."......_ PF.RMYTIDATE:_ /d t •'0 C�rM.riLtAAiC i A'r sepataticz Distance Bctweea the: - A3azimusnAd;usis-tiC�rouodwaierTah€ctnthef3c>tttimzri.,ear3iiity,Faciiity Priyaw Water S.PP$'Weil and Leaching Facility. (rf any wet ex4t on site of_jdji t 200 feet of kachaug facility) F;dne of Wedand.and Lzaching Facility(1f any'wc"-nC6 cs si within 3W.fcct..of iearchi-g facili#y.).: �----.•...,..w----- :cE 2.0 -30 , 0.. y._ 0 03 14 � t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owners Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ■❑ Surface water Check cellar ■❑ Shallow wells Estimated depth to high ground water: a below SAS feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed: July- 21-1999Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form I91 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main Street Route 6A Property Address Robert Gustafson Owner Owner's Name information is West Barnstable Ma 02668 6-6-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ■❑ A. Inspector Information: Complete all fields in this section. Q■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked �■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed 0■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 These variances were granted because the new proposed septic system will replace an older substandard system, which "failed" during a recent inspection. The proposed system meets the maximum feasible compliance standards contained in Title V, the State Environmental Code. Sincerely yours, Susan R.S. Chairperson Board of Health Town of Barnstable SGR/bcs 1492RT6A f YOU WISH TO OPEN A BUSINESS? / q-Z �C For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. n. y w�,, _ DATE: Z u ' a Fill in please: n �ng � _ L APPLICANT'S YOUR NAME/S: CC USi i S gW Kim 'P ri� BUSINESS YOUR HOMEADDRESS: 114c) & MA'Al 7,1 , r . TELEPHONE # Home Telephone Number FO° '3`1I V,7.3 NAME OF.CORPORATION:' �', r.ti..�✓V C l w C, NAME OF NEW BUSINESS 2 TYPE OF BUSINESS f% wa�/Ce4 IS THIS.A HOME OCCUPATION? YES NO. U ADDRESS OF.BUSINESS. I I.I� ` I`r et i jL�` ,,lZ twi MAP/PARCEL NUMBER I 7 04 c (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH t, This individual has b informe �tpe r ter quirements that pertain to this type of business. rize Si n COMMENTS: 3. CONSUMER AFFAIRS (LICENSIN AU HORITY) This individual has be infor d t e licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: r- Town of Barnstable P# J Department of Health,Safety,and Environmental Services opVEPublic Health Division Date Q, 367 Main Street,Hyannis MA 02601 HMMEMABM MASS, A K.l Argo s Date ScheduledAgY /G/99 Time �O'l l Fee Pd. — Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: 10 YL At iv,C7 t LOCATION& GENERAL INFORMATION Location Address Owner's Name G � rr L Address /4j(_19,2�r —A?(7"�_4 Assessor's Ma /Par�:����•!' p.� Engineer's Name �v NEW CONST'RRUCTION REPAIR DC Telephone# y29_ 3 C/ 9 Land Use I�C I DE Al T7 ts.L Slopes(/) J ° t�a `r Surface Stones ot„1 E vL�St4�t M Distances from: Open Water Body ft Possible Wet Area 100- ft Drinking Water Well 100t ft Drainage Way ft Property Line 1 0 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) r ,cam, � 1 1 N o , � r 774-r N � IS` vy 92 ,erg q p0 ✓� G � N 1 gt L L- �J3 ZZ� r ,� r 1 Parent material(geologic) LA"'C- ;?Sfft tT-6 Depth to Bedrock Depth to Groundwater: Standing Water in Hole: l n"a Weeping from Pit Face Estimated Seasonal High Groundwater .. . DETERII­11NA ON 'E Yt SIJASUI�AL DtG V 'EtZ' `� t. Method Used. 065��lA.T16 Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: 7,'S " in. Groundwater Adjustment ft. �- Index Well# .Reading Date:_ Index Well level.-__ Adj.factor Adj.Groundwater Level .. PER+COL A'TION TEST' vat� me t l'A t to CJ.a,a-at_C To 1 m'—C.. iE to Observation Hole# FA:EFF Time at 9" Depth ofPerc tZ^Irp1 L_Y CL&5S( -I E`7 Xl�s A Time at 6" Start Pre-soak Time @ C t'ASS �vA Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division set Data TO Be Completed on Back j Copy: Applicant Q OAt Q �p�„ „ >^ t\16U :DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. l-1 ZZ,4 Consistent °o Gravel) v�h K 1 oY 2�1 w OU-D C-cow.ooS�O �lJ d .3 ©e,caw%e. Nn,�TTG 6 F^ 12" O $AMr>5C%\At �Q�Q.S�IZ N 00.>C. 'MCo 20E7tr, %LL 1 t�.A\M mFI'X>&O (aptJ4llOr'Qj,t� l'1 61J r n V1L ToD Fit. VAA- -p62i+.IV\> ' C , �vL1�.�.F7 1dY2 5l6 4 C11A S—ooTb1 f,ABp4.?PT r -GS r e--j PC A-5TtC-A in e.K 20 CzIrl. I�rS 1✓L l;,® ATT E �f- ���1 ,$) Cg gA�� �oye.s/qTO O,5CC--2A-A C'F-� --192 1:�� CA ....Sur�LQT DEEP OBSERVATION HOLE L+(JG - Hale Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency-Y Gravel DEEP:OBSERVATION;HOLE LOG Hole# . . . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistent %Gravel I k DEEP OBSERVATION HQIE LO;G Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,°oGravel) Flood Insurance Rate Mao: Above 500 year flood boundary No Yes Within 500 year boundary No_ Yes K_ Within 100 year flood boundary No DC Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? "o If not,what is the depth of naturally occurring pervious material? 3 5 t C t Certification I certify that on AQVZI c, ss (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature , Is 1,�� Date 16V 1s`9D Two Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M •y''� 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 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. A. General Information s 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Cityrrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that 1 have personally inspected the sewage disposal system at this address and thafthe 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 1'6.340 of Title 5(310 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Failsa r=R ❑ Needs Further Evaluation by the Local Approving Authority cis AK 1-23 1- 2 _ I Inspector's Efignature 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. 1 ��v t5ins•11/10 _ Title 5 Official Inspection A 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 ,M 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Barnstable MA 02668 1-23-12 required for every ' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information'which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 13 System Conditional) Passes: Y Y ❑ 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f - s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection` Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 1492 Main St (Rte GA) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) - Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ❑ ® due to an overloaded or clogged SAS or cesspool ❑ ® 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 'h day flow t5ins•11110 • 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 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS:*cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system 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- 1 0,000g pd. O+ ® 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Z ❑ 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 (f 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Well water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 12-2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Retail/Office Design flow(based on 310 CMR 15.203): 90gpdGallons per day(gpd) Basis of:design flow(seats/persons/sq.ft., etc.): 50gpd/1000sq ft Grease trap present? ❑ Yes 0 No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes E No Water meter readings, if available: Well water t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 } Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1=800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 12-2011 Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 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 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page_ Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal 101, Sludge depth: t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 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 22" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 51 Official ,Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. City/Town 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•11/10 _ Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today'Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. Cityfrown 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.): Good condition with water at working level and no sign of back-up from chambers. 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.): Pump chamber in good condition with pumps and alarm working as designed. Soil Absorption System (SAS) (locate on site plan, excavation not required): I.fSAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5-500's ❑ 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.): Leach chambers in good condition with water level and stain line at 10" below inlet invert. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt G Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. City/Town 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.): r 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. City/Town 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 - Dc A 0-z or t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 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: 89"feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans on file show groundwater was encountered at 89" below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 YA I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °,M y 1492 Main St (Rte 6A) Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 1-23-12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t / y\y • �M See TITLE 5 OFFICIAL INSPECTION. FORM-NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION; Property Address:.lzzlow- Owner's Name: 4- Ohil!Aknn Owner's Address: 10-'& F Date of Inspection: /-2/i �— REQ1��D Name of Inspector: lease print) ,4'16k r' �.1 �Lt3f`t� �U �EC Company Name: �� l v��• .11 U0� . Mailing Address: Ll ©�� TOW EALTH D STAB!E 2EPT. Telephone Number: ,52 X- ` L>/ ' 9-3 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at:this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was at 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 . Xai ds.I uJthen Evaluation by the Local Approving Authority s/ A 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 I0,000 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. Notes and Comments ****This report only describes conditions at the time of inspection!and under the conditions of useat that time. This inspection does not address how the system will.perform.in the future under the same or different conditions of use: Title 5 Inspection Form 6/15/2000 page 1 .Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A- CERTIFICA.TION (continued) Property Address: , pca2 U Owner:: Date of Inspection: Q7 Inspection Stimmary: Check A,B,C,D or E%ALWAYS complete all of Section D A. ystem Passes: I have not found any information which indicates that any of the failure criteria described in 310,,CMR .. _ 1`5.303 or'in 310 C1v1R 15.304 exist.Any failure criteria not evahiafedare indicated below: 4 . 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 ofthe replacement or repair, as approved by the Board of Health, will pass. Answer yes;no or not determined(Y,N,ND) in the for the following statements.,If"not determined"please explain. The septic tank is metal and over 20 years old* or.the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or,tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as'approved by the Board of Health. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 year's old is available. ND explain: 41 Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settfed or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: c 2 Page 3 of 1.1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: ` Date of Inspection: 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`Hea1!h.determines hi accordance-with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which.will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. .System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and.SAS and the SAS is within a Zone 1 of a public.water supply. The system has.a septic tank and SAS and the.SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a private water supply well**. Method used to determine distance; **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic corrpowids indicates tliat the well is free orn pollution.�om 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. J 3. Other: 3 Page 4 of 91 OFFICIAL.INSPECTION rORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _ alze d� Owner: Date of Inspection: A 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 ischarge 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 '/2 day flow Required pumping more than 4 times in the last year NOT dice to clogged or obstructed pipe(s).Number / of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. lAny 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 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 feetbut.greater than 50 feet from a private water supply well-with no acceptable water quality analysis. [This system passes if the well water analysis, performed:at a DEP certified laboratory;for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the.presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other faihire criteria are triggered.A copy of the analysis must be attached to this form.] ,L=--(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 system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the.failure. 1:. Large Systems: To be considered a large'systerh the system must serve a facility with a'design low of 10,000 gpd to;15,000 gpd• You must indicate either"yes"or"no"to-each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no . _ the system is within 400 feet of'a surface drinking water supply the system is within 200 feet of.a tributary to a surface drinking water supply — _ the system is located in a nitrogen-sensitive area(Interim Wellhead Protection Area—IWPA)or'a mapped Zone 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. '4 ..e Page 5-of 1.1 OFFICIAL INSPECTION FORM NOT FOR VQILUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART B CI-IECKLI,ST Property Address: A T A J/, t�4 Owner: ,af-j' dA-.!,a Date of Inspection: _L �MI6 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 tine owner, occupant,or.Board of t�eaitl;: a✓Were.any of the system components pumped out in the previous two weeks? r/ _ Has the system received normal flows in the previous two week period? _ Have large..voluntes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility.or dwelling inspected for signs of sewage back up Was the site inspected for signs of breakout? Were all system components,excluding the SAS, located on site _V/�_ Were the septic tank manholes uncovered,.opened,and the interior o.fthe tank inspected for tile 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).pro.vided 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 — Existing information.For example, a plau.at the Board of Health: J Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 R Page"6 of 11 OFFICIAL INSPECTIOI�I-FORM NOT FOR VOLUNTARY ASSESSMENTS SUIISURrACE SEWA GEDISPOSAL SYSTr1Vi INSPECTION FORM :I'ART C SV�TEM 1Ni+'OR*MATION Property Address: 02 Gam" ZIL Owner: iyl Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(.design): . Number of bedrooms(actual): DESIGN flow based'on"310 Cv1R 15.203 (for example: 110 gpd x N of bedrooms): Number of current residents: r_ Does residence,have.a garbage grinder(yes zor no): U ' Is laundry on a separate sewage`system (yes or no):. Q f if"yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no):.-W .. Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): nO Last date of occupancy:0UJ COMMERCIAL%INDUSTRIAL Type of establishment: Design flow.(based on 310 CMR.15.203): gpd Basis of design flow(seats/persons/sgft etc.): . Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):'_ Water meter readings, if available: Last date of occupancyA..ise: OTHER(describe): GENERAL INFORNIATION Pumping Records . Source of information:. Was system.primped as part of the inspectio �6 &M n(yes or no); d f If yes, volume pumped: gallons==14ow was quantity pumped determined? Reason—for pumping.- TYPE OF SYSTEM Septic tank,distribution box,soil aysorption system Single cesspool _Overflow cesspool _Privy _Shared system.(yes or-no)(if yes,attach previous inspection records,if any) Innovative/Alternat_ ve technology.Attach a copy of the current operation and maintenance contract(to be obtained from system oiwner) Tight tank _Attach a copy:of the DEP:approval _Other'(describe): Approxim to a e of all components date lest ]led(if known)and source of information: Were sewage odors'detected when arriving at the site(yes or no): �� L Page 7 of 1 OFFICIAL INSPECTION FORM-NOT F OR VO}LUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: j Co w Owner: Date of Inspection: ' � — BUILDING SENVER(locate oil site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other.(explain): Distance from private water supply we'll or suction lire: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: e/ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance (yes or no):-(attach a copy of certificate) Dimensions: /O V5�X C2 1; Sludge depth:_V f l Distance from top of sludgZ,e to bottom of outlet tee or baffle: 1,f7 Scum thickness: & �I Distance froth top of scum to top of outlet tee or baffle: Distance fi•orn bottom of scum to botton outlet tee or baffle:._ How were dimensions determined: �7 C � p�c C/ Comments(on pumping recommendations, in orlet and outlet tee baffle condition, structural integrity, liquid level/ Ae,,,,ted to outlet invert,evidence of leakag etc.): ' /✓ GREASE TRAP:_(locate on.site plan) Depth below grade:_ Material of construction:,concrete metal_fiberglass,polyethylene_other (explain):_, Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,.evidence of leakage, etc.): 7 Page 8 of l 1 OFFICIAL1INSPECTION.oRm—NOT FOR rVOLUINTARY ASSIESSMENTS S.UBSURFACE SEWAOE:D.ISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION N(continued) Property Address: , Owner: Date of Inspection: 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 Plow: eallons/day Alarm present(yes or no); Alarm.level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): Q DISTRIBUTION BOX: ✓ . (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evicdence.of solids carr),over, any evidence of . leakage into or o it of box, e ez1.4 PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms,in,-working order(yes or-no); Comments(note condition of pu 1p 11 ber, conditi n of pumps and ptenances, etc. : v 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION(continued) Property Address:, i (� Owner: Date of Inspection: . / SOIL ABSORPTION SYSTEM(SAS):.Zlocate on site plait,excavation not required) If SAS not located explain why:.. Type leaching.pits,number:_ 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, PumzmAe�"Oj _ l 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 or no): Comments(note condition of soil,.signs of hydraulic failure,ievei of pohdirig,conditio i 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.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' t. ,D'ART C 5 SYSTEM INFORMATION(continued) Property Address:.` �f Owner: p-7 Date of nspection: r SKETCH Or 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 I00.feet. Locate where public.water supply enters the building. � d A � 61.E wo 103 0 B' . q y � a oy O 10 Y Page I I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: lq9,,2- Owner: Date of Inspection: ZO— SITE EXAM. Slope Surface water Check cellar. Shallow wells Estimated depth to ground water lr feet Please indicate(check)all methods used to'determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 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: �r✓ 0 11 ='tf Permit Number: Date: ;Y r. > s Completed by:. HIGH GROUND VV'ATER LEVEL COMPUTATION] Location:Site L I `7 �� to tor- sy> (�1� � /ri ,5I;;l le Lot No, ,gi7 Owner: �� J� G9d� Address:_ Tf *; Contractor: ® Address: Notes: STEP 1 Measure depth to water table J to nearest 1/10 ft. ...................:................... ......................... . .Date / .Z 3�I..: ..... ....... .. i month/day/year - I STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well...:................................................ I�✓.�d1/ OWater-level range zone ..............................................:.......l!J STEP 3 Using monthly.report "Current Water Resources Conditions" / determine current depth to �J /�� �y�I water level for index well ........................... —/ `Z month/year. STEP ,4 Using Table of Water-level adjustments for index well (STEP 2A), current depth to water level for index well (S.T EP 3), and water-level zone (STEP 2B) � determine water-level adjustment ...............--..-....-.........................................................-........ f STEP d Estimate depth to high water by subtracting.•the water- levO adjustment (STEP 1} from measured depth to water �� level at site (STEP 1) .............. .....................:.. Figure 11—Reproducible computation form, 1.5 9 �f r' -- ladle,,��nh=h :pv7 57 ti r Sullivan Engineering Inc. 7 Parker Road Box 659 Osterville MA 02655 Peter Sullivan.P.E . Mass. Registration No. 29733 Phone 508-428-3344 Fax 508-428-3115 e-mail: psullpe@aol.com April 13, 2000 Board of Health Town of Barnstable 367 Main Street Hyannis, MA 02601 RE: 1492 Main Street (Route 6A), Barnstable Dear Board of Health, This letter is to certify that I inspected the septic system installation at the above referenced project. The septic system was installed according to the plan. Please note that the vent pipe is to the rear of the property where it can be screened by vegetation. I trust this meets your present needs. If you have any questions, please feel free to contact me. Ve truly yours, Peter Sullivan P.E. Sullivan Engineering Inc. cc: Bortolotti Construction Members of American Society of Civil Engineers, Boston Society of Civil Engineers I TOWN OF BARNSTABLE CF 7H E TO OFFICE OF i Haaa9Te� i BOARD OF HEALTH bASI �p 1639. \gym 367 MAIN STREET HYANNIS, MASS.02601 November 1, 1999 Peter Sullivan 7 Parker Road Osterville, MA 02655 RE: 1492 Route 6A, West Barnstable A=197-48 and 49 Dear Mr. Sullivan: You are granted variances on behalf of your client, Robert Creighton, to replace the onsite sewage disposal system located at 1492 Route 6A, West Barnstable, Massachusetts. The variances granted are as follows: • Part Vill, Section 10.00: To install a soil absorption system only 63 feet away from a vegetated wetland and only 73 feet away from a watercourse. Also, the reserve area was designed to be installed only 69 feet away from the wetland and only 70 feet away from a watercourse. 310 CMR 15.240: To install a soil absorption system in an area where there is only 3.5 feet of naturally occurring pervious soil. These variances are granted with the following conditions: (1) The designing engineer shall supervise the construction of the septic system and shall certify in writing to the Board of Health that the system was installed in strict accordance with the submitted plans dated July 21, 1999. (2) The existing septic system components shall be pumped-out and removed as stated on the engineered plan. 1492RT6A TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE G1+��f.96�.Y-47.454/to ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEP--1C TANK CAPACITY KaO I14L!W,0 LEACHING FACII.ITY: (type) (size) NO.OF BEDROOMS / BUILDER OR OWNERAll Cam'i l't4/1 PERMITDATE: COMPLIANCE DATE: t� i Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Within 300 feet of leaching facility) Feet Furnished by ^C l 1 t 4 - c,1 i TOWN OF B.ARNSTABLE LOCATION /����°� MGL,- 'h S f �� /9 SEWAGE # -- - VILLAGE IN. �Ct/n 5 /T,�b�C ASSESSOR'S MAP&LOT INSTALLERS NAME&t PHONE NO. SEPTIC TANK-CAPACITY 1' GAG LEACki[NG FACIII'T. Y: {typa) a!ov (size) NO.OFBEDROUMS 3 �" BUILDER OR OWNER- PERMITDATE: C011MIANCE DATE -- Separation Distance Between tbe: Maximum Adjusted;Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching facility (If arty sells exist on site or witbin 200 feet of leaching facility) Feet_ Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o eaching facility) Feet Furnished by � G✓'� —` ��j' -- r K A 6 0 � � C Jo ' o0 30 � -/00 � - r_'°3 .4 13-�-,?? ��'� or _ V- ".and 6'"� V --- TOWN OF BARNSTAIRLE 1!- LOCATION Nie Z kpjli//�' SEWAGE # VILLAGE I b-fl)��4zMe ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �SrOO l0©G� rOLll�is® LEACHING FACILITY: (type) s®® a'j G Obi (size) NO. OF BEDROOMS P 1 JP0 S f +e BUILDER OR OWNER1 JG '® PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 3© , �3 Fr l ? r O O ` 0 o. �A / / �7� so � N Fee ✓✓/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for �Ngpool *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(r)Abandon( ) WcompleteSystem ❑Individual Components Location Address or Lot No.lq Q� � / Owner's N;e?,Address and Tel.NNo. Assessor's Map/Parcel 77 �� ��� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. pw�f 5&,1114,vo V Type of Building: _ �Y� 41l �edroLo Dwelling No.of Bedrooms t Size sq. ft. Garbage Grinder( ) Other Type of Building 110- A'-1j et No.of Persons Showers( ) Cafeteria( ) Other Fixtures / U yr r Design Flow ;o gallons per day. Calculated daily flow gallons. Plan Date Z Z Q9 Number of sheets / Revision Date vj a Title Size of Septic Tank Type of S.A.S. Jeee I/1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 0&1 ENGINEER MUST SUPERVISE Date last inspected: I,!STALLATEON AND CERTIFY IN WRITING THE SYSTEM WAS INSTALLED IN, STRICT Agreement: ACCORDANCE TO PLAN. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is B ar of ealth. Signed Date J� Q Application Approved by - o Date Application Disapproved for the following reasons Permit No. _7 ( Date Issued — /7 pit- No.! / / •7 7 K W Fee i THE COMMOTi WEALTH OF MASSACHUSETTS Entered in computer: 11 Yes PU -LIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETT-t , a , ,,Rp-plication for �Digogal *pgtem Congtruction ermit Application for a Permit to Construct( )Repair( )Upgrade(011)Abandon( ) Complete System O Individual Components Location Address or Lot No.I�JQ� Q /1 Owner's N e,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. //i 7) Type of Building: Dwelling No.of Bedrooms Z Lot Size sq.ft. Garbage Grinder ) Other Type of Building No. of Persons Showers( ),Cafeteria( ) t Other Fixtures I-'/✓1`l_i1 Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. _Description of Soil ._Nature of Repairs or Alterations(Answer when applicable) 7 Date last inspected: Agreement: 'The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until Certifi- cate of Compliance has been issued by this Board of ealtfii Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. ��— 7.7 ( Date Issued /7- - --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ' �► 7 p y BARNSTABLE, MASSACHUSETTS QCertif icate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(-sO')Upgraded(P") Abandoned( )by Ld 6o _577 at Z&/ zI4" has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - / dated/— / 7— Installer Designer 'The issuance of this pe ' shall n be c,. sirued as a guarantee that the to will funnct'on as des gne , V Date Inspector 0 t/d� U� 0 l I --------------------------------------- ...- No. Fee # THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS wigpogar *pgtem (tongtruction Vermit Permission is hereby granted to Construct( Repair( )Upgrade(i,<A bandon( ) System located at Z and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. QQ Date: ��— /7 —�9 Approved byW, �-�J dAl[ DATE: FEE • ,narsrnets, , REC. BY Town of Barnstable Board of Health 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Ralph A.Murphy,M.D. VARIANCE REQUEST FORM LOCATION /J p Property Address: �7 Q 7- I` Assessor's Map and Parcel Number: l 7 g'y ' Size of Lot: Wetlands Within 300 Ft. Yes Subdivision Name: No Business Name: APPLICANT r J / CONTACT PERSON Name: r�O�er� Cry%9``f�'� Name: fe Address: I W2- kA-1 W Za're.57-A' re Address: 7 �U��L'✓� l aSl��v/rle Phone: 7,3 Z- — ,f5-z-/?Z'-/z"6-- 5,?Zz Phone: V Z FAX: 47 Z T - 13 FAX: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) heck& (to be completed by office staff person receiving variance request application) Four(4)copies of plan submitted(including septic system plans and/or restaurant floor plans) Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variances only) (►�'� P/�Variance request application fee-collected[no fee for lifeguard modification rene„al&,grease trap variance renewals[same ownernessee onlyL outside dining variance renewals[same ownerAeasee only[,and variances to repair failed sewage disposal systems[only if no expansion to the building proposed)) [ )))✓Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Ralph A.Murphy;M.D. Q:/WP/VARIREQ x 1/2•IaGaly 24"0Opening Above For M.H. Finish Grode DESIGN DATA OTES Float Support Frame B�Cava. Pp 3 Bedroom:3 x l lO=330GPD t Water SupplyForT'his Lot is a Private Wetl. Filter No Garbage Grinder 1 Location of Utilities Shown on This Pion Are rox. . �•' �'�'�� �'•'''• � Fabric Compacted Fill -"f Commercial:1800 S.F. APP 50 Gal/1000 S.F.=90 G PD At Least 72 Hours Prior to Any Excavation ForT6is Pump Power6 Float Control To D-Box sN ■ Daily Flow= 420 GPD Project The ControctorSholl Make The Required Cables Installed in Accordance Septic Tank:420 GPD x 200%=8406PD Notification to Dig Safe(1-800-322-4844) With Local Bldg.B Elec.Codes. \ Pea Stone Use 1500 Gallon Septic Tank 3 The Contractor is Required to Secure Appropriate! LEACHING AREA Permits From Town Agencies For Construction Leaching — Defined byThis Plan. a 4'�0 From.Septic precast Pump � ■ ■ 420 GPD/0.74=568 SF Required le of Sch.40 PVC a Chamber _ 3/4 -1 1/2 ' Use Bottom Area Only 4 Install Risers as Requiredto Within 12 of 8 0' Chamber S Double W° Bottom Area=12'x 50=: 600 S.F . Finished Grade. L_ 4-10 I 600 SF.Total Provided 5.All Structures Buried Four Feet or More or Subject' �" +••r' �:' e' �_ ' LEACHING CHAMBER DESIGN to Vehicular Traffic to be H-2-0 Loading. Use a 1000 Gallon Septic Tank. •+ All Pipes to be Schedule 40. Use 6 Septic System to be Installed in Accordance With 5-500 Gal.Leaching Chambers Ina 310 C M R 15.00 Latest Revision And The Town of PLAN CROSS SECTION OF CHAMBER 12'x 50'W°shed Stone Field as Shown Barnstable Board of Health Regulations '-.:NOT TO SCALE- 7. All Piping to beSch 40 PVC. qrge 0 Sch.40 PVC Finished F.G.25.0 om Septic Tank Grade F.G.24.0 ! 22.0 r.a • � i r22.5 f, TnpEl.23.0 2 2.3 2.2 Bat.E1.20.0 Conduit Thru Chamber ri 1500 Gallon Pump For Powerl�Fbat Galy. :' To D-Bax Septic Tank Chamber ' Eme Storage o Cables. Chain a; Min.2'Cover �L J 5 0 Vol.437 Ga I Inv.22.3 ^.�,:• :y- Ground Water @Fl.15.0 Alarm on EI.2 ' 2'�0 Sch.40 PVC Bedding as Remove Unsuitable Materil Fcr 5A11 Around Mercu Float y Per Title $" System&Replace With Clean Class 1 PumponE1.20.1 _ Switchss-3Req'd Threaded Pipe Material. DEVELOPED PROFILE OF-PROPOSED SEPTIC SYSTEM Pump off EI.18.5 Check Valve Not to Scale Secure Pipe of Top 9 Bottom of Chamber I �� Bottom El.17.5 a:• 6"Washed •,E. •a. V ; j Stone Min. iWo SECTION T PUMP CHAMBER DETAIL Waterproof/Seal Pump Chamber Not to Scale With Approved Sealant. Seal All Penitrations Watertight. i r SULLIVAN NO.29733 l CIVIL s .r SIX?fr, c • 1L e i 1 � SULLIVAIN ENGINEERING INC, SHEET ?- of 2 OSTERVILLE, MASS. 1492 ROUTE 6A DATE: JULY 21_1999 W. BARNSTABLE, MASS. J 99026 . ova as keys PN� Marahh« j?�Ss�th s / ( /Tenn Cen LOCUS \ tra/ \\\ \S 44 b1. / \ Pand a y 6 \ ,Jp" �A a LOCATION MAP \ a 1 I iPRIMARY , ' 1 //1 / 1 $gs?O. (1"=2000f) — 1 PE P, i v o MADRA- 8�8--0 REFERENCES: 69 PRIY Assessors' map 197 E Parcels 48 & 49 IN, \ / SOR.K Zone: RF 3 \�\ 1\\ j j /• w i_1 I / 11 1 LI M'T West Barnstable Fire District 1 \ % I / / �� _I I 1, Old Kings Highway Regional Historic Dist O ro/ra vvottk L / I W I I 'y E STAKD so I I y H&N BALE S FEMA Zone. A3 & C (see plan) rC mA I T ; N // Community Panel # 250001 0011 D /� �� / 6' I z' 6 117' 3 I 1 Revised July 2, 1992 RGSEI J N I I Aquifer Protection District 4,9'PRJMgRy as per "Revised Groundwater ter Protec Overlay District" Map Dated April 19 En 1 I Lot Area: 1.96± Acres T. 00 At 10 "Ir I. /// // �P// '�. �{ Ili I Off / / / / / / - �C, o f 2k'� / CHAMg / / o �� �v :, O Iron Pipe // �// // b *r n" O ■ MHB (Mass Highway Bound) / •/ / / // tiK CD Cb p O PK nail 4 / '" O Gu / lo�/ I / / / ? StJ, zo, w°Z O Utility Pole i— �• / / q�?`t*' #/49? 0) Well ?CIK Deciduous Tree Coniferous Tree Sign - Wetland Flag (by vegetation) _ =26— — Index Contour ———— Minor Contour / 1 67 anw Overhead Wires __24 NOTE: EXISrINf, SHPTIC SYS"TEMTOFbG PuMPED ou-r d- RcMOVED, OR \ 6' ISL 29) MHB \ FND PREPARED FOR. Ra Notes v ision: F' F 1.) THE PROPERTY LINE INFORMATION SHOWN WAS COMPILED FROM RECORD INFORMATION AND IS NOT THE RESULT 41 60RTOLOTTI CONSTRUCTION INC. OF AN ACTUAL SURVEY ON THE GROUND. 45INDUSTRY ROAD 2.) THE TOPOGRAPHIC INFORMATION SHOWN WAS PREPARED ' .' x.,,... MARSTONS MILLS , MASS. FROM A CONVENTIONAL GROUND SURVEY PERFORMED ON OR BETWEEN 25/APRIL AND 2/MAY/95. 3.) THE DATUM USED IS MEAN SEA LEVEL (MSL 29). pa le/d �R � H Draft: R L H 4.) THE BENCHMARK USED /S 792 J, A MASSACHUSETTS DPW DISK STAMPED "92J-17.972" LOCATED AT THE O�Y1 at LH`y Review: PS INTERSECTION OF THE RAIL ROAD AND ROUTE 6A AT ` Drawing # "PROCTOR'S CROSSING" EL = 17.972' PLANT WITH I ' t=�scuL 1 o�i,�� I � o 'f HOLE CT.F-1.) EL_ I 's0 00.6 EL, S \ MOT-rorA o F \ CIFSAND INe SY$TEM Mi- Zo'o \ 73 NOTE: Remove Unsuitable Material For 5 � All Around System 81 Replace With i c2 `p Clean Class I Material. $ / 1b 2�V 0C39EQVEp GRaUNp • WATt3R ,lk / MAD, COARSE C3. SAND ,g//• � �' E.L.13,p � •� /• LLJ •ts '— o b Wetlond Limit N h as Flagged by F.E.S./ p►7 N April 30, 1995 CLAY 2 Cy AL Limit of A.C.E.C. Devotion 11 / as per CZM (301CMR 20.%,25)A) BOTTOM T M. CL. („5- M.E.P.A. (JOICMR 10.17, / JL / I Perc Test P-9396 Date 5/18/99 _ 10 SElnc. P.Sullivan B of Health Donna Miorandi Test Ho% 1 �. i 0%3" O Dark Loamy Sand 10YR2/1 __ -w;__ 3"-6" A Loamy Sand,few roots 10YR3/2 _'— ———— —— a - 6"-12" 13 Sand some Loam _ 4 \ 10Y1?5/2 —_ — — " G, --i'eur Fine,,sand 10Yit5/6 14 36"-72" C2 Gray Clay 5Y5/1 — __————— 72%114" C3 Med.To Coarse Sand 1 OYR5/4 —— _ —— •�� 114"-192" is C4 Gray Clay 5Y5/1 _ ' Water Encountered @ 7.5'—Elevadon15.0.Perched between two clay lenses. Not Artesian B Unable to pert due to depth and caving of test hole.Water was freely flowing from sidewall at a veryfast rate. Ee °j ° p 7S34 ` T 1 ns PO�na,r ? \ \ \ The C3 lens readily classified as: Class 1 MatertaP—Less 2 minutes per inch con 1 I Variances Required �� N °c°e'e,,,,,� 1. Town of Barnstable Part VIII:On Site Disposal Regulations �.` \\ Section 10.00 Onsite sewage Disposal Construction subsection 1.13 Rt �/f"No Person etc.—shall install a leaching facility within 100 feet of \ `J a watercourse as defined in Title 5." �•� \ I I Setback provided is 70'to expansion and 73'to the primary. �•. Q I I Please note that Title 5(1995)does cot define a watercourse. I I Reason for Variance I. Maximum Feasible Compliance applies to items 1 dt 2 above. Cone Variances Required PLAN VIEW ednen l l 1. 310CMR15.240 Soil Absorption System(1)-4'feet of naturally a occurring pervious soil required below the system.There is 3.5 feet existing. Scale:1 3.0 2. Town of Barnstable Part VM:On Site Disposal Regulations Section 10.00 Onsite sewage Disposal Construction subsection 1.13 T.B.M. Elewotlar "No Person etc.—shall install a leaching facility within 100 feet of '• PK Nall set In a watercourse as defined in Title 5." k Setback provided to BVW is 63'to expansion and 69'to the m pri ary. Please note that Title 5(1995)does not define a watercourse Reason for Variance 3. Maximum Feasible Compliance applies to items I&2 above. ' Ttle: PREPARED BY- co SEPTIC SYSTEM UPGRADE C. Sullivan Engineering, Inc. Vap� 149� ROUTE 6A PO Box 659 9 Porl WEST BARNSTABLE , MASS. Osterville, MA 02655 Osterville M. (508)428-3344 (508)428-3115 fox (508)402-3994 (508)402 O PSul1PEVbol.com copesurv60c 30 0 15 30 .60 Dote.: Scale: JULY 21, 1999 AS SHOWN G.