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HomeMy WebLinkAbout1540 MAIN ST./RTE 6A(W.BARN.) - Health 1540 Main Street gym. West Bamst�ible A= 1,97-("15 v i f a f �. _x, t�� �l..d.��w� /)) y y �t�✓ � �Y.SL.1"� �-Y i m { R . t� � �" � i '� _ � I -:, � �� � j I ,$ti M TOWN OF BARNSTABLE t. LOCATION 1�q8 SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL U INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ,y L�O 1��� d�L • �. ��{t`(J; LEACHING FACILITY:(type) (size) NO-.OF BEDROOMS /J OWNER ``PERMIT DATE:�a`s�-1 COMPLIANCE DATE: "Separation Distance Between the: _= `IV;Wrnum 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 o��efl � —fir av/ IV 41 'V No. 2 —0 Y✓ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: E PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ltlflration for MispoSal 6pstrm Construrtion Permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No.I J q® & _t_,Pr Owner's Name,Address,and Tel.No. 5O$7 /_�6�5-� Assessor's Map/Parcel /9 / W' 'M� , /yu 6 x.. Installer's Name, ddress,and T 1.No. 620E-qa&-S7 Designer's Name,Address,and Tel.No. Cyr-6lat-8®v - - ,cm yne- ,'V1� `T'u�l�13nl AILU oat elk Type of Building: Dwelling No.of Bedrooms A)A( Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /W gpd Design flow provided /L)A- gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when.applicable) 's1f-i' - Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Co not lace the system in operation until a Certificate of Compliance has been issued by this Board of Health. c� /4*!ed Date Application Approved by �-""— Date Application Disapproved by Date for the following reasons IX Permit No. 7i®(of Date Issued 6&1 a / � No. ;_ Fee�./ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Misposai 6pstem Construction 3permit Application for a Permit to Construct( ) Repair k) Upgrade( ) Abandon( ) ❑Complete System ['Individual Components Location Address or Lot No. (� Owner's Name,Address,and Tel.No. e "M&a�. 44,E tAtcllf-- 15Q 6/W4 Assessor's Map/Parcel /,7 W I&-014aC-61 til Installer's Name,Address,and Tel.No. �j$•(/a$.�Sa(v Designer's Name,Address,and Tel.No.�1 r cc) cm , Taj1z.6n&,, Type of Buildingl Dwelling No.of Bedrooms AA Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design F ow(min.required) 4 W gpd Design flow provided '�,:IU 4 gpd Plan Date Number of sheets Revision0ate Title Size of Septic Tank Type of S.A.S. 1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) c?Pr�{-rk '16e4Il .L�L1]JYP&A � �).friXr�i7'r/� ypi n ItN't4�A��it.vt.^ � ��` • Date last inspected: ................. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in r accordance wil the provisions of Title 5 of the Environmental Code,and no place the system in operation until a Certificate of Compliance has been issued by this Board of Health. x i O ed " ^'^"----� Date Application Approved by Date Application Disapproved y Date for the following reasons Permit No.Wlq 1,3G Date Issued ------------------ --------------------------------------------------------------------------------------------------------------- L THE COMMONWEALTH OF MASSACHUSETTS V^k BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TOCERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(kf Upgraded( ) Abandoned( )by GCr{o)rjc at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated r r Y �.7 Installer f Jo C 04211—Ye-t r 44 ,rY Designer k #bedrooms AA Approved design flow gpd The issuance of this permi shall t be construed as a guarantee that the system will nc' s designed. Date ` Inspector a_� r �- - - - ct--, ------- ---------------------------------------------------------------------------------------------------------- No. — Fee THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Vermit Permission is hereby granted to Construct( ) Repair(.�) Upgrade( ) Abandon( ) System located at r �q6 IL (/ } /o yA,}art ,.°1 a(�n and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:C tion must be completed within three years of the date of this permit. Date '� Approved by _ i Y l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. Cityrrown 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 RE A?, i I I it o o A fl$ — 4- 85ra-(o 1 2 II 3- $ 56- 0 � 3 i�I- IN- 0 5 t t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i I l Stanton, David From: Stanton, David Sent: Friday, February 22, 2019 8:36 AM To: 'dgonsalves@downcape.com' Subject: RE: Septic Tank Question Hi Danny, I just spoke with Tom, here are the options: 1. Pour a slab on top of existing tank with a PE to certify it is H-20 rated (no Board of Health hearing required) 2. Replace tank same location with H-20 tank (needs Board of Health hearing) 3. Replace tank to comply with Town code (100' away from the well: no Board of Health hearing) 4. Replace tank in another location, but less than 100' from well (need Board of Health hearing) Thanks, Dave From: dgonsalves0downcape.com [mailto:dgonsalves@downcape.com] Sent: Thursday, February 21, 2019 10:35 AM To: Stanton, David Subject: RE: Septic Tank Question Dave, That is good to know. Thank you for the quick response and I will look forward to Tom's opinion. Thanks, Danny E. Gonsalves, PE Professional Engineer Down Cape Engineering, Inc. Tel:508-362-4541 Fax:508-362-9880 This Electronic Message contains information from the engineering firm of down cape engineering, inc., which may be privileged. The information is intended to be for the use of the addressee only. If you are not the addressee, note that any disclosure,copy,distribution or use of the contents of this message is prohibited. From: Stanton, David <David.Stanton@town.barnstable.ma.us> Sent:Thursday, February 21, 2019 9:22 AM To:dgonsalves@downcape.com Subject: RE: Septic Tank Question Hi Dan, I will have to review it with Tom when he returns (hopefully later on tomorrow.) Tom has allowed in the past to pour some extra concrete over the tank to make it H-20, with the only catch that a PE certifies that it meets H-20 loading 1 requirements. The catch is on this one, the tank (pre-existing) is too close to the well (Town of Barnstable requires a 100' setback from septic tanks to wells, so I don't know if he will allow work to be done on a non-conforming septic tank for a new project.) Thanks, Dave From: dgonsalves@downcape.com [mailto:dgonsalves(abdowncape.com] Sent: Wednesday, February 20, 2019 3:23 PM To: Stanton, David Subject: Septic Tank Question Dave, Barnstable Land Trust is planning on adding some additional parking in the rear of their building. They have an existing H-10 septic tank which will be under the proposed parking. Can we pour some extra concrete over this tank to make it H-20?Otherwise we could move the tank 10' away from the parking lot. I have attached the latest sketch for your reference. Let me know what you think. Thanks, Danny E. Gonsalves, PE Professional Engineer Down Cape Engineering, Inc. Tel:508-362-4541 Fax:508-362-9880 This Electronic Message contains information from the engineering firm of down cape engineering, inc., which may be privileged. The information is intended to be for the use of the addressee only. If you are not the addressee, note that any disclosure,copy,distribution or use of the contents of this message is prohibited. CAUTION:This email originated from outside of the Town.of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe! CAUTION:This email originated from outside of the Town of Barnstable! Do not click Finks, open attachments or reply, unless you recognize the sender's email address and know the content is safe! 2 Commonwealth of Massachusetts Title 5 Official Inspection' Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St r— IND Property Address CO 1540 Main Street, LLC Owner Owner's Name information isMl required for every W. Barnstable ✓ MA 02668 7-13-2017 page. City/Town State Zip Code Date of Inspection J�4 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information �-- filling out forms ��$� 2'� "T� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone use the return Name of Inspector key. jCape Cod Septic Inspection �y Company Name P.O. Box 1466 Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM 16.000).The s tem: ® Pa es ❑ Conditio s Fails El❑ ed urt Eva the Local Approving Authority 7-15-2017 nspector's Signatdr.V Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �Oq,#VS Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. ' Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is-imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 0.Y ❑ N . ❑ ND (Explain below): t Siins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The 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 r ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: . I 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 1/2 daY flow t5ins•3113 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 w, 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and.chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M s 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 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? El ® . Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts 43) Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2 bedroom multipurpose dwelling Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Private well Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2014Date Commercial/Industrial Flow Conditions: Type of Establishment: Gallery Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 1500 sqft Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: private well t5ins-3113 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 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Discount Septic Pumping 7-2015 (508)240-2500 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1976 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 10 +/- 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.): Apparent good condition Septic Tank(locate on site plan): Depth below grade: 4"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: 1000 gallon Sludge depth: 0" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W Barnstable MA 02668 7-13-2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" 0,l Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid level No sign of leakage Concrete outlet tee OK Recommended next maintenance pumping within 2 years Recommended maintenance pumping every 2-3 years 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•3113 Title 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 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. City/Town 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.): Grade to box 8" OK condition 3 outlets with equal flow Normal liquid level No sign of leakage No scum No sign of failure Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•3/13 .. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 (18x18x0.5') ❑ 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.): 1(18x18x0.5')field Grade to field 10" Bottom 22" Clean and dry stone No sign of hydraulic failure 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 l5ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 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.): 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.): 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 page. Cityrrown 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 i � f I 1 Z 1 A }[$ 3 2 N 3- B 56 o 3 051- Ili 0 6 J t5ins•3113 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts' . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7-13-2017 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: >4 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: 1976 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation:' Test hole results from the original design plan on file with the Health Department. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w v Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1540 Main St Property Address 1540 Main Street, LLC Owner Owner's Name required for is every W. Barnstable required for eve MA 02668 7-13-2017 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts rp ' 01�5 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rya ,. 1540 Main St.W. Barnstable, MA , - Property Address 1540 Main Street, LLC r- Owner Owner's Name information is W. Barnstable required for every MA 02668 7/2/15 -1: page. Cm State Zip Code Date of Inspection IA Q1 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone key the return Name of Inspector y Cape Cod Septic Inspection Company Name P.O. Box 1466 �---�� Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Pas ❑ Conditionally Passes —❑ Fails ❑ N s urther valua ' th Loc proving Authority 7/5/15 In ctor's Signatur 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. I V L !Sins•3f13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7/2/15 page. Cityrrown 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: The septic tank was pumped after the inspection B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts ; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .0 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is W. Barnstable required for every MA 02668 7/2/15 page. Cloy own State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The 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): ❑ r obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts fD Title 5 Official Inspection Form u_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 540 Main t. W.S Barnstable , MA Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7/2/15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well_ ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow 15ins•3113 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal system.Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection ti p Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7/2/15 page. Clty/Town State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owners Name information is required for every W. Barnstable MA 02668 7/2/15 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? P g ® ❑ 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 er al of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) D. Sy stem Information Residential Flow Conditions: Number of bedrooms(design): - 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins-3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form ,o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 1540 Main St.W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is W Barnstable required for every MA 02668 712/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: 2 Bedroom multipurpose dwelling Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Private well Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2014 Date Commercial/Industrial Flow Conditions: Type of Establishment: Gallery Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 1500 sqft Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: private well t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts a1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7/2/15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Discount Septic Pumping (508)240-2500 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Weight Reason for pumping: Maintenance 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•3113 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 wM 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is every W Barnstable required for eve MA 02668 7/2/15 page. dkir own State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1976 Per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material 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.): Apparent good condition Septic Tank(locate on site plan): Depth below grade: 4" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: 1000 gallon Sludge depth: 24" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form_ Sub surface ace Sewage Disp osal System Form Not for Voluntary Assessments '..,, 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7/2/15 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 8 Scum thickness 12" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 5" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle.condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid level No sign of leakage Concrete outlet tee OK The septic tank was pumped after the inspection Recommended maintenance pumping every 2-3 years Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /V 1540 Main St. W. Barnstable, MA M Property Address 1540 Main Street, LLC Owner Owner's Name information is W. Barnstable required for every MA 02668 7/2/15 page. Clty/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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 712115 page. Citylrown 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.): Grade to box 8" OK condition 3 Outlets No scum No sign of failure Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required).- If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal S - 9 p System Form Not for VoluntaryAssessments s essments w.. 1540 Main St.W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owners Name information is W. Barnstable required for every MA 02668 7/2/15 page. Cm State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 (18x18x0.5) ❑ 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.): 1 (18x18x0.5')field Grade to field 10" Bottom 22" Clean and Dry stone No sign of hydraulic failure 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 ElYes ❑ No t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1540 Main St_ W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is W. Barnstable MA 02668 7/2/15 required for every 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.): 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-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St.W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is W. Barnstable required for every MA 02668 7/2/15 page. Cltyrrown 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 I i N/O Z A B ` - -3 7-F i 53-- b 3 3- q 3 131-41 i Illy- C) \� 6 � fsins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is required for every W. Barnstable MA 02668 7/2/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >41 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: 1976 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole results from the original design plan on file with the health department Before filing this Inspection Report, please see Report Completeness Checklist on next page. I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1540 Main St. W. Barnstable, MA Property Address 1540 Main Street, LLC Owner Owner's Name information is W. Barnstable required for every MA 02668 712/15 page. Cityfrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 N• 1 • i Page: 1 of 1 CERTIFICATE OF ANALYSIS ,MI Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 9/15/2016 Steven Flynn JMW Real Estate Order No.: G1696663 2655 Main Street#27 Brewster, MA 02631 I Laboratory ID#: 1696663-01 Description: Water-Drinking Water Sample#: Sample Location: 1540 Main St.West Barnstable Collected: 09/13/2016 Collected by: Steve Flynn Received: 09/13/2016 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE i Nitrate as Nitrogen 0.19 mg/L 0.10 10 EPA 300.0 LAP 9/14/2016 Copper 0.13 mg/L 0.10 1.3 SM 31116 LAP 9/15/2016 j Iron 0.24 mg/L 0.10 0.3 SM 3111 B LAP 9/15/2016 1 pH 5.5 PH AT 25C NA 6.5-8.5 SM 4500-H-B DCB 9/13/2016 Sodium 320 mg/L 2.5 20 SM 3111B LAP 9/15/2016 i Total Coliform Absent PIA 0 0 SM 9223 RG 9/13/2016 Conductance 1,500 umohs/cm 2.0 EPA 120.1 DCB 9/13/2016 Sodium level is above the maxium contaminant level. Those on a!ow sodium diet may wish to consult a physician. Approved : Attached please find the laboratory certified parameter list. pp B Y (Lab Director) Ole, 1 I i I i i i I I I ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level i 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I I 'Qe�pE�iAR�J, ; CERTIFICATE. OF ANALYSIS M' Barnstable County Health Laboratory (M-MA009) y�.lClilS�� Recipient: Steven Flynn Matrix: Water-Drinking Water JMW Real Estate Sampled: 09/13/2016 12:30 2655 Main Street#27 Received: 09/13/2016 12:55 Brewster, MA 02631 Collection Address: 1540 Main St.West Barnstable Order#: G1696663 Sample Location: Lab ID: 1696663 01 Description: 5 Day RUSH-1540 Main St.W.Barn, Date Analyzed: 9/13/2016 @ 11:00 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Sodium level is above the maxlum contaminant level.Those on a low sodium diet may wish to consult a physician. ........--- - f EPA 524.2- Volatile Organics by GC/MS - .......- - _ - - .......... Result MCL MDL ResultMCL MDL Parameter ug/L ug/L ug/L Parameter ug/L ug/l ug/L rEchiorodifluoromethane ND 0.50 Chloroform ND ao 0.50 Chloromethane ND 0.50 cis-1,2-Dichloroethene ND 70 0.50 Vinyl chloride ND 2.0 0.50 cis-1,3_Dichloropropene ND j I 0.50 _........-- - . Bromomethane ND 0.so� Dibromochloromethane ND 0.50 _ ----_ - - - - -- 1,1,1r- 2-Tetrachloroethane ND I 0.50 Dibromomethane ND 0.50 1,1,1-Trichloroethane ND 200 0.50�Ethylbenzene ND 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,2-Trichloroethane ND 5.0 0.50 Isopropyl benzene ND 0.50 lI,I_Dichloroethane ND I 0.50 1 Methylene chloride ND 5.0 0.50 rl� 1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl ether ND 0.54 __... 11,1 Dichloropropene ND 0.50 Naphthalene ND - 0.50 1,Z,3-Trichlorobenzene ND o•� n Butylbenzene ND 0.50 --.... - ... -.... - .....--- -- --_... ---.... -- - ._.. 1,2,3-Trichloropropane ND 0.50 n-Propylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 a,5o p-Isopropyltoluene ND 0.50 F1,2,4-Trimethylbenzene ND 0.50 sec-Butylbenzene ND 0.50 1,2-Dibromo-3-chloropropane _ ND t).5o Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ND 0.50 tert-Butylbenzene ND 0•50 1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichloroethane ND 5.0 0.50 Toluene ND 1000 0.50. _-........ -.. --.......- - -. _ _..._.._ 1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50 11,3,5-Trimeth (benzene -�-ND 0.50 trans-1,2-Dichloroethene - ND 100 0.50 13-Dichlorobenzene ND 0.50 trans-1,3-Dichloropropene ND- . O.So -- --.... -......_.__ ........-- - - .... - ._.._.. - --._....._. _.._... �1,3-Dichloropropane ND 0.50 Trichloroethene ND 5.0 , 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Trichlorofluoromethane - ND 0.50� 2,2-Dichloropropane - ND 0.50 Surrogates %Recovered QC Limits(%) i2 Chlorotoluene ND 0.50 Bromofluorobenzene+ 95% 70 130 iorotoluen 4-Che ND 0.50- p 0 - -_- 1,2-Dichlorobenzene-d4 89/0 70 130 Benzene ND 5.0 0.50 - _.....__ _ ---.....-- .....- .... _..__ Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 - -----..... - - _ Carbon tetrachloride ND 5.0 0150 Chlorobenzene ND 100 0.50 I- Chloroethane ND 0.50 -- ....... -..._-..._...._.-_..........--..... -............ ..... J Attached please find the laboratory certified parameter list. Approved By. -...----- (Lab Director) � � ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Le-veI 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 608-376-6605 Page 1 of 1 i R. A. Bous#ield Backhoe Service 17 Burbank Street I�(� _ Sandwich, Massachusetts 02563 Name .am—pli Permit No. Location: �04 �,L) Builder's Name and Address '� 7 ® Date Permit Issued: Date Compliance Issued:. '1 i s , tic Finc THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... ...........OF.....:. Appliratiun -fur Uhipoiitt1 Norkii Tunitrurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: G'� �� Gar ltJ ���wfr/96�� Location-Address or Lot No. +'--��--------------------------------------------------- -- �::.� 3iv 1�# % _ 7 Qwper C Address J O �!c f� A� �Q �� Installer Address Type of Building Size Lot.... 66 =�` d YP g __ Sq. feet,{=,�.5' U Dwelling—No. of Bedrooms--------------9_..........._.._....___..Expansion Attic ( -� Garbage Grinder a4 Other—Type of Building ._-- ------- No. of persons.-_-___�___----_-----_ Showers (A) — Cafeteria ( ) a Other fixtures --------------- ------------- - W Design Flow............y.��.O.................... .gallons per person per day. Total daily flow............. D !�-__-------..---gallons. P4 Septic Tank—Liquid capacity------d_ gallons Length---------------- Width.......--------- Diameter._--__..-__--.-_ Depth--_.--.-._..-.. W f __ Width-----------------"-- Total Length Total leaching Area____. _0 s ft. x Disposal finch—No. __�e.____ .:.. g g ---------- q• Seepage Pit No. .... Diameter.................... Depth below inlet.................... Total leaching area_-_---_-.--___--sq. ft. z Other Distribution box ()() Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date......................------------------ a Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water------__"---.-----._._- �14 Test Pit No. 2....._----------minutes per inch Depth of Test Pit-------:............ Depth to ground water------------------------ ---------------------------------------------------------------------------................................................................................. xDescription of Soil----------- TrZ � ------3� U --•--------•--•-•-•--------------------------- --•-----••--•••---•••--•----••••--••-••-••-•----•-------•-•---------•--•----------------------------------------------- x ----------------------------------- ------------------------------------------------------------------------------------- --------------------------------------------------------------- V Nature of Repairs or Alterations—Answer wheW applicable applicable.._....... a � . -------•----------------------------"---------------- <ifr C-- .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beAn issued byw" e b f health. Signed. • ----.---•-- -------- -- •...............••......------. J� Date Application Approved BY-------- ---/ ------------•-•-----------------------------------•----- Date Application Disapproved forte following reasons----------------------------------------------------------------------------------------------------------- ---•--------•------------•---...•---•-----•-•----------------•••-•-----------••---•---•-- Date PermitNo...... ..........................•-----•....... Issued........................................................ Date i I L i No...... / Fig.......I .....G.0 -a•..., THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .................OF..................................... .- - ApphrFation -for l i ipoiittl Morkii Tons#.rurfion Puniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -- ---- -1--- . - ---------------------- ......------------........... Location-Address or Lot No. / C_A/ n %per C Address QU Es S'F/e�d J/� c�lti / /� s?. .............-/---.------•---•----•-------------••--•--•-----•-----•-••----•-•-•....... ------•----.t�-_-----------�...,/'_.r Installer Address f Q Type of Building Size Lot-...7'-66._-----______Sq. feet S U Dwelling—No. of Bedrooms-------------- 19.-------__ -_--.--.-----Expansion Attic (--j Garbage Grinder ( -} per, Other—Type of Building ."-__ ------- No. of persons........A............... Showers ( A) — Cafeteria ( ) a' Other fixtures ---------------------------------- W Design Flow................ . )_..________.______,gallons per person per day. Total daily flow............. .._..U.._........_..gallons. P4 Septic Tank—Liquid capacity_.'._�'_ gallons Length---------------- Width................ Diameter___.._.--._.-_ Depth---.--..-.------ Disposal Trench—No.. !� ��--_- Width-------------------- Total Length-------............. Total leaching area----- !?_ ------ ft. Seepage Pit No..- ..... Diameter-------------------- Depth below inlet------------........ Total leaching area------------------scl. ft. z Other Distribution box (�<) Dosing tank ( ) Percolation Test Results Performed by----------------"--------------------------------------------------------- Date.------------------------ --------- W Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...-_"._-_--_.-.------ f4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-_.--_____--._.------ P4 --------------------------------------------------------------------------- .......--•'••••'--••-.......................... .............................. O Description of Soil Soil-"--_----..-. e. �_- C ,1/w ' - 7 � ------- -------•----7. ... - U -------------------------------------------- ------ --------------------------------- W x ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ 12 ----------------- -----•---•--...- ........................... -"--------••----------------------------------•----•--•--••----------•------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued by e bq�rqf health. f Signed. 1�' -- =••- i !� Date ApplicationApproved By------------/.................................................................. -------------------" -------------- Date Application Disapproved for the following reasons:----•------------------•------------------------------------•---•-•-----------------.-------------------------•- -•........---'...................••.._.._...-•---•--•---------..........-•---'-----•--•----••--------•-•-•••--•---...--••'•--------------•---------•-----------•----....----•-----------.----•-•----•--- G Date PermitNo. ......................................... Issued--------------------- .................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J�f�- 1 .....................OF......... 1/ tiJ /hf,CC Trrtif irate of Toutphattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( -'Tor Repaired ( ) Installer at..................= ,f/ ' At------ �� _----------•------ l f�------•-•------ -!- 0-'h�h ,r/�, has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No............C Y..................... dated..... ...-_.; `f: -7 THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM Wl NCTLON SAT SFACTORY. DATE........... /' `... Inspector. THE COMMONWEALTH OF MASSACHUSETTS f T - /� �'Z BOARD OF HEALT�Fi / ...................... ...................OF................,.......................-- --------------------------.............. No...... ........... FEE_..................... Di jivii al fork Cron #ratr ioat rani Permission is hereby granted............. z!! ~.. --•--•-•----------------•------------------------•---•------------.._..----------.--------------••-... to Construct ( <) or Repair ( ) an Individual Sewage Disposal System atNo---------------t�----........................................` '� c - l j ,�?----....---/>.. - -------------'•---------------------------.....---•-••........ Street as shown on the application for Disposal Works Construction Permit No.....ZYI� ....... Dated...._`/_� ------ ............... /r DATE_ j�Iealth FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ..E i •! ' ^;'Tr "�f-Jam.- •/2 t. ' 0 7 c ' :51 = - �✓Y�! '� t: _,:, Ma 5uc5t� GONQ(fw5 -rD 1"46 r �*rPnat / r 7 y �5D I • _- VIN NA f�. .' � �L l��•�14`f —`.,''-��.. . �:1'�tfvt«.'+�'L.� {"',•4ti'tNcs �`�- ��y,, , + r t� m Town of Barnstable P# Department of Health,Safety,and Environmental Services OFI Public Health Division Date �. 367 Main Street,I lyannis MA 02601 . HARNSTABMM„as. _� . Date Scheduled �"m lX� Tilne Fee Pd. & e.�Y^ •t � .. ' (Soil Suitability Assessment for Sewage Disposal Performed By: J AH I:5 V0KJ0\Jk w 6.5�& Witnessed By: POO NA ...... ......... FORM INAT�OV URA ....... ... � Aa N _..:. ..... :.:. Location Address Owner's Name IS40 HAIM ST• �WVM GA) BAMA12A Foe_10 KEEL WIES-f 1131L1t QSTAl LF, HA Address P.O. Fox (,ZZ Assessor's Map/Parcel: M AI? I97/ PA(2C.>!¢t, 15 Engineer's Name I.344 G UIVI01 NEW CONSTRUCTION X REPAIR Telephone N 71>J• &5rl. -71 p, Land Use J? 9"lV9l YM -\ %tJS"MLL; Slopes 6• Surface Stones W6 O BSOKU0D Distances from: Open Water Body R Possible Wet Area /SG Z It Drinking Water Well "5" 7,j It Drainage Way R Property Line sb i2 J (t Other n SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locale wetlands in proximity to holes) � I t 6VW • _ � ��51 t'IT l.ot�Tli7u5 Bu A2� �PI'RD�IMaTaE AP?A�� guw )e �� qg.3 �fTAIL HSE Y Parent material(geologic) fLA LACIAL_ MWASH Depth to Bedrock 5 T e Or4T A Depth to Groundwater: Standing Water in Ilole: /56E 770 19474 Weeping from Pit Face 515E ly P474 Estimated Seasonal High Groundwater Q-�1^(I $' , , t�{�"Z ('i,• . ) `l -3 C q.�o 1 ::> :: :: :a:>:...........:............:...:........... ....:...::..........:...:,....;;::.......:<,;:..:. ...,...;.,.:.. ;,.,......:......:;....:.:,:.......,...:,;...............:....<.::. :: bE'I'ERI NATIt7Ir1. t�R SEASONAL,: GY2'Y'AT3L ;>: ......<.:.» Method Used: C1lWtivxiOWhPE(t. AO�UgfM�µT .... ::::..... ..... Depth Observed standing In obs.hole: S01F T>D OgTA in. Depth to soil mottles: 56,f_ 7P DATE) in. Depth to weeping from side of obs.hole: 60 7P DATA in. Groundwater Adjustment -Index Well N Reading Date:I_ZL-11 Index Well level L4-,_b_ Adl.factor-1,!J— Adj.Groundwater Level_5015 V Q4771 ;:<::.;.;::::;<;:»:;::::: ;. I'EI2CLLAT01 TEST Hate �tme: .�i� .; . ;:... . .. ...�.. Observation QQq Gf, G �/ �• Hole 1 1'( l"1-Z !-3 Time at9 p: Depth of Perc 6AXH,;3) taa Time at 6" /0., 11''07 /f Start Pre-soak Time Q 10`2!/ 114• Yy Zor Time(9"-6") C� *4�P,09/ .7 *IN 3 Mi/✓ End Pre-soak Rate Min.Anch La?MO/ �,tMO/ 1_1.2 AJ4P1 Site Suitability Assessment: Site Passed_ Site Failed: Additional Testing Needed(Y/N) A Original: Public Health Division Observation Hole Data To Be Completed on Back j Conv: Anolicant Er O sEt �mto�r t >� �G ItA # Depth from Soil Horizon Soil Texture Soil Color Soil Oilier r Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. n �-/Z SG !�J'/I y z .vE G,t,Agce 5TAu°,uy kgIFL A0AIE led/g GE g ..2 - o G SAND (&,;y $4m* 50"P, WAW APJ . /,q .Z oasf S/A/ A PT 4 goo tuATra -s./ /l A W460 DEEP` OBSERVA,TI0NHUL>L BOG Hole:# � _, • Depth from I Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % 2 - .� /QrR y L � tid�it�,E Fi2,q � STANDiAJ4 WA7M /06 � w�>E�/N� - �ovE 12 - 30 gw 5 L- log -5 8 �0V Aflof Ott `36 -IYV G 54 v0 .2S 6 y N Mea/U&I Sgtva x�°• �»<a ADJ. C AOT. riRN�. wATEK• -6.9'OfsfAve '10W S/Nb 1-E 4/ZA4/r10 DUP I' OT3SERVATIONICIY. t.dG Dole# Depth from Soil l lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. e SL /v 19 y�Z /f10/(/F t9 4 64 St4uaA4 w,17,FX - /3 A AV SL /0 yR s g Avv vE F9/484 tE we EoiN4 - Alooe yf- IVV, G SjjN>~� a?•5 y 6 waiJ4 tiV v0/v09 -SgNo RND. W47,Frl AOJ• - /9 ' Gg5&RU� .r!ooSf SiNyGE ADJ. �',r�ur�, aATt�2. 9;6• � q O . DCEP OISP�2VATION HOLE LOB Hale#.. Depth from Soil horizon Sol Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. e Flood dnsurmup Pate:l:ap1 r^dMMv N 1Tr \P',¢it/�L �5000/ 0O//p� 'e V15 Fil9 Jt y 2, /"Z (2o�t1E C� Above 500 year flood boundary No_ Yes x // Within 500 year boundary. No x Yes Within 100 year flood boundary No x Yes Depth of Naturally Occurring Pervinua 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,? E5 If not, what is the depth of naturally occurring pervious material? Certification I certify that on APR/G / f7 (date)I have passed the soil evaluator examination approved;by tl.e 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 1.5.017. Signature Date-0,2•3- �9 �.A ............ 7 ow 7( ELL �l fit" z N pil -1-AP (JU 77 ct, 54� "r.14 3\� ir Vill ud 7'