HomeMy WebLinkAbout1595 MAIN ST./RTE 6A(W.BARN.) - Health 1595 MAIN ST. RTE 6A
W. BARNSTABLE P
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David B. Mason, RS
Certification of a Title V Design/Installation
Location of System: 1595 Main Street (Route 6A)
Plan prepared by: David B. Mason, R.S.
Type of Inspection: Installation
Date: August 1, 2002
I, David B. Mason, Registered Sanitarian, duly licensed in the
Commonwealth of Massachusetts, do hereby certify that this firm
has visually inspected the soil excavation for the type of
inspection noted above as shown on the referenced approved plan,
and further certify that for the inspection conducted at that
time and required, that as constructed, such generally conforms
within acceptable tolerance to the regulations, as varied, set
forth in 310 CMR 15.000 and the Town of Barnstable Board of
Health regulations.
Such certification shall not be misconstrued as a guarantee that
the system will operate satisfactorily nor certification of
alterations after inspection.
� Z02,
id son Date
4 Glacier Path, East Sandwich, MA. 02537
508-833-2177
COMPLETESENDER: COMPLETE THIS SECTION ` SECTION . DELIVERY
■ Complete items 1,2,and 3.Also complete A. Re i ed by(Please Print Clean y) B. Date f Delive
item 4 if Restricted Delivery is desired. � ri c5�t'n ^�'j^
■ Print your name and address on the reverse
so that we can return the card to you. C. i ature
■ Attach this card to the back of the mailpiece, X r Agent
for on the front if space permits. Addressee
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
SIP
` �/►� 3. Service Type
❑Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number(Copy from service la— 7002 0 510 0001 9503 803
0
PS Form 38111 Juuly 1999 Domestic Return Receipt 102595-00-M-0952
COMPLETE •N COMPLETE THIS SECTIONON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Da of Delivery '
item 4 if Restricted Delivery is desired. F/,-�b� Of�f���
■ Print your name and address on the reverse
so that we can return the card to you. C. Signat e
■ Attach this card to the back of the mailpiece, X ❑Agent
or on the front if space permits. Z-- El Addressee
D. Is deliv address different from item 1? ❑Yes
1. Article Addressed to: i If YES,enter delivery address below: ❑ No i
J rUW s{ i
IL4 to 0 KIN✓ W4
1,1, �-/t'• '/_`1/��/ f' u�I� 3."Kice Type
u/ I't1(�`^j�iJ��'��(/Y/ ••I{/'� Certified Mail ❑ Express Mail
1 ❑Registered ❑ Return Receipt for Merchandise
O ❑ Insured Mail ❑C.O.D.•
4. Restricted Delivery?(Extra Fee) ❑Yes
002 0510 0001 9503 8009
- 3 Deic Return Receipt
Jy 102595.00-M-0952
SECTIONSENDER: COMPLETE THIS
■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Date jO Delivery
item 4 if Restricted Delivery is desired. d4MCekl_ �}
■ Print your name and address on the reverse
so that we can return the card,to you. C. Signature
■ Attach this card to the back of the mailpiece, X ❑Agent
or on the front if space permits. 044' ❑Addressee
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
Lx
3: Service Type' Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑,Jrisured Mai
"' ❑C.O.D.
g4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number(Copy from service label) ,
'�p�OG'd/ y 80l(
PS Form 3811,July 1999 Domestic Return Receipt 102595.00-M-0952
I
,> (3) The applicant shall record a properly worded deed restriction, signed by
the owner of the property, at the Barnstable County Registry of Deeds
restricting the property to five (5) bedrooms maximum. A copy of the
recorded deed restriction shall be submitted to the Health Agent prior to
obtaining a disposal works construction permit.
(4) The applicant and/or owner shall not expand the office and retail uses at .�
this site in the future without first obtaining written permission from the
Board of Health.
(5) The septic system shall be installed in strict accordance with the revised
engineered plans.
(6) The Registered Sanitarian shall supervise the construction of the onsite
sewage disposal system and shall certify in writing to the Board of Health
that the system was installed in substantial compliance with the revised
plans.
These variances are granted because the physical constraints at the site
severely restrict the location of the soil absorption system due to the proximity of
private wells in the area. It is the opinion of this Board that the proposed new soil
absorption system will be constructed to meet the maximum feasible compliance
standards contained within the State Environmental Code, Title V.
Sin erely your ,
yn . Miller, M.D.
Chair
Mason
DATE: 6 /)7AZ
PER: N
8AANsrAsr.E,
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grass. R$ BY
ArEp�a,�
Town ®f Barnstable S®. DATE:�06--,")-
Board ®f Health
200 Main Street,Hyannis MA 026.01
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kaufman,M.S.P.H.
Wayne A.Miller,M.D.
VARIANCE REQUEST FORM
LOCATION ���•9,� ^/)�/� �5 s�0� '7� 0,
Property Address:
Assessor's Map and Parcel Number: 197 Size of Lot: '
Wetlands Within 300 Ft. Yes iusiness Name:
No '�j< Subdivision Name:
APPLICANT'S NAME: —2D4L)I p 23. 1MA 5W1 26 Phone 5*00— { 5— z 7 7
Did the owner of the property authorize you to represent him or her? Yeses No
PROPERTY OWNER'S NAME CONTACT PERSON ! /
Name: 11Z L Name:
15q5 MWI� Address:
Address: 1.
,.• b 1
Phone: Phone: Zot O
ARIANCE FROM REGULATION(test Reg.) REASON FOR VARIANCE(May attach if more space new
►Ot>Jlra � '�jV�I�d cS�P77G 13��f'� Lam" �g/c�
NATURE OF WORK: House Addition E3 00000 House Renovation 13 Repair of Failed Septic System
Checks't(to be completed by ogee staff1mmon reset g variance request application)
Four(4)copies of the completed variance request form
Four(4)copies of engineered plan submitted(e.g.septic system plans)
Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant Idtcben plans)
Signed letter stating that the property owner authorized you to represent bim4w for this request
7 Applicant understands that the abutters must be notified by certified marl at least ben 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 variance requests only)
Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same
owner/leasee only],outside dining variance renewals(same owner/lessee only],and variances to repair failed sewage disposal systems
(only if no expansion to the building proposedl)
_ Variance request sub m itted 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 Wayne A.Miller,M.D.
Q:\HEALTH\WPFILES\VARIREQ.DOC
V
Irina Weatherly
1595 Main Street
W. Barnstable, MA
May 29, 2002
i
To Whom It May Concern,
I, Irina Weatherly, hereby authorize Mr. Dave Mason, as my
engineer, to represent me in matters before the Board of Health
regarding the installation of a septic system on my property located at
1595 Main Street, W. Barnstable.
Thank you for your consideration in this matter.
Respectfu ours,
4U,
Irina eatherl
I
David B. Mason, RS
J
Abutters List
25 Parker Road Earle & Denise Coffman
P.O. Box 850
West Barnstable, MA 02668
424 Plum Street Robert Ritucci TR Paint Realty Trust
P.O. Box 664
West Barnstable, MA 02668
1611 Main Street Robert Ritucci TR Paint Realty Trust
P.O. Box 664
West Barnstable, MA 02668
1610 Main Street Gregory & Elizabeth Miller
1610 Old Kings Highway
West Barnstable, MA 02668
1596 Main Street Joseph & Joselle Dellamorte
1596 Old Kings Highway
West Barnstable, MA 02668
4 Glacier Path, East Sandwich, MA 02537
508-833-2177
17
41
�• Town of Barnstable
g, Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,RS.
FAX: 508-790-6304 Sumner Kaufman,MSPH
Wayne Miller,M.D.
July 17, 2002
Mr. David Mason, R.S.
DBC Environmental Designs
East Sandwich, MA
1 91%taiE , .. t6 estB rnsa 7 Y4
Dear Mr. Mason,
You are granted conditional variances, on behalf of your client, Irina Weatherly,
to construct an onsite sewage disposal system at 1595 Main Street, Route 6A,
West Barnstable.
The variances granted are as follows:
PART XII: The new onsite soil absorption system will be located 140 feet away
from the new onsite private well, in lieu of the 150 feet minimum
separation distance required.
PART XII: The abutter's soil absorption system (located to the east of the
subject property) will be located 120 feet away from the new onsite
private well, in lieu of the 150 feet minimum separation distance
required.
The variances are granted with the following conditions:
(1) The Registered Sanitarian shall provide revised plans to the Public Health
Division showing relocation of the proposed soil absorption system ten
feet further to the south, in order to provide the required minimum
separation distance of 150 feet to the neighbor's well (located to the north-
east.
(2) No more than five (5) bedrooms maximum are authorized at this
property. Dens, study rooms, offices, finished attics, sleeping lofts, and
similar-type rooms are considered "bedrooms" according to the MA
Department of Environmental Protection.
Mason
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TOWN OF BARNSTABLE
LOCATION 6 SEWAGE # 2 0a2 2 d
VILLAGE �U�^fTA 2 ASSESSOR'S MAP L& OT I97'0Y%
INSTALLER'S NAME&PHONE NO. 60 UY LIP ki
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 500 6-1L C (size)
NO.OF BEDROOMS .
BUILDER OR OWNER eoj e r
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Rarilit,If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
Feet
within 300 feet of leaching facility)
Fumished by
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TOWN OF BARNSTABLE
L�#CiON �2S M�
l I'' b SEWAGE # 2 oda-3a o
VILLA'GE We-4- �jr^r^J�A6� ASSESSOR'S MAP & LOT 9 -0Y
INSTALLER'S NAME&PHONE NO.6(1 ul o
SEPTIC TANK CAPACITY l SUO LEACHING FACILITY: (type) 6-144 C 1ykw ko (size) Ly
NO.OF BEDROOMS
BUILDER OR OWNER er LiC'r�
PERMITDATE: Uz COMPLIANCE DATE: ? I D
12
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility 41f 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
LOT NO'. • ADDRESS*-+���i
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OWNERS N01E: j l
SEWAGE PERMIT NO. NEW: REPAIR:
DATE ISSUEll: - --e2,DATE INSTALLED:
NSTALLERS NAME : Aoulr-`, sai
-a�
I NSTALLATI0:1 OF:150a Sr=5rp 4.,'.
WATER TABLE: FINAL INSPECTION BY:
DRAWING OF INSTALLATION ON REVERSE SIDE :
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No.
MlelhfEc Fee -
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Migoml *pgtem Congtruction permit
Application for a Permit to Construct( )Repair X)Upgrade( )Abandon( ) it Complete System' ❑Individual Components
Location Address or Lot No.1 s9 5 R 7 bA w eJ 7 f3 4,-IV Owner's Name,Address and Tel.No.
�v_M'4
Assessor's Map/Parcel 'q -? Ll I /LT 6,4
Installer's Name)Address,and d Tel.No. Designer's Name,Address a rd Tel.No.
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14c %4v 9e16 -A,v l3ox `fg2-
PO✓-e6 l3l 1 M 0 z 33 3! 77
Type of Building:
Dwelling No.of Bedrooms 5 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building Re.-f"s , / No.of Persons Showers( ) Cafeteria( )
Other Fixtures r
Design Flow w/J 7 gallons per day. Calculated daily flow 6 0 q gallons.
Plan Date //—/Y"O/ Number of sheets / Revision Date '7—/t/—0 2
Title
Size of Septic Tank / 5?60 Type of S.A.S.
Description of Soil See &Ar1
Nature of Repairs or Alterations(Answer when applicable) 9WIACe X J'? l6ac� ?<fi✓� '�
�
Date last inspected: THE SYSAEON�AND:.���i��;v CERTIFY ISUr✓..'N
Agreement: AC AS WAS INSTALLED (NWRITING
The undersigned agrees to ensure the construction and maintenance of the afore described on-siteeaFposal systB TRiCT
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 this Wealth
Signed r o Date ��ZD•-U 2
Application Approved by Date
Application Disapproved for the following reaso
Permit No. — Date Issued
0q0 MielAIVC6 C Fee r
[� Entered in rn uter:
THE COMMONWEALTH OF MASSACHUSETTS � p yes
PUBLIC HEALTH.DIVISION - TOWN Oi BARNSTABLE MASSACHUSETTS
s
01ppYtcatton for -t oga1 pe;tem Construction Vermtt
Application for a Permit to Construct( )Repair(x)Upgrade.( )Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. )Sq S R r bQ (iuQJ7/6.4/^/ Owner's Name,Address and Tel.No.
7i-e MA Gv e'G
Assessor's Map/Parcel IC? -7 ,y s 5 Y- /1 T 6/4
q Installer's Name,Address,and Tel.No. o ;.. Designer's Name,Address and Tel.No.
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lyc ZrAN Seh4S4,A.-V Sox 'f4�- C�s� A. 0
Gores 64 /.e wt O z& 33 0�/ 77
Type of Bailding:
�
Dwelling No.of Bedrooms .J C Lot Size sq.ft. Garbage Grinder:( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures I
Design Flow gallons per day. Calculated daily flow le O q gallons.
Plan Date //" /41— 0/ Number of sheets / Revision Date 7`1 V—0 2
Title
Size of Septic Tank / 5-00 Type of S.A.S. -4 ecaeh 60.4 4-e S el-DO)
Des'cription of Soil Se e- .91
Nature of Repairs or Alterations(Answer when applicable) ?ele,J/fie -e A-.f, 7 4iv
A//.[a/ /4
,lllate last inspected:
Agreement: _
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system 1
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 this ar f ealth.
~� Signed Date -7-20—U Z
'Application Approved by / Date
Application Disapproved for the following reaso
Permit No. c Date Issued
----------------------------- ----------
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` THE COMMONWEALTH OF MASSACHUSETTS.
r
BARNSTABLE, MASSACHUSETTS
Certef tcate of Comprtance , f'
THIS IS TO CER�� that the On-site Sewage Disposal System Constructed( )Repaired ( SC)Upgraded( )
Abandoned( )by _8CXJJ CAP /C( 5,4r1 i-4,46e!�!'w ,2i L'i c-e 2'k, c-
at/.5-9,r- 7'&A UO e. S -7 6Ace has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer SR444 iy Designer 7)&C -e V&1.,'•
The issuance ots limit shall not be construed as a guarantee that the systqf will ,f ction as des' ed.
Date i Inspector
---------------------------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
/eo PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
1� Mtq gar *pgtem Conztructton Vermtt
Permission is hereby granted to Construct( )Repair V)Upgrade( )Abandon( )
System located at /S-7 S 9-/ 4 A
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:Constructio- must com eted within three years of the date of tfe)r:t /
Date: Approved by
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Town of Barnstable
wwsrne�, + Department of Health, Safety, and Environmental Services
. Public Health Division
367 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: KENNETH & ELEANORE LUDWIG DATE: JAN. 20, 2000
1595 MAIN ST.
WEST BARNSTABLE, MA. 02668
ORDER TO COMPLY WITH 310 CMR 15.00, THE-STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 1595 MAIN ST. RTE 6A was inspected on 02/21//97
by JAMES D. SEARS a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of
1995 TITLE 5 (310 CMR 15.00) due to the following:
BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN
OVERLOADED OR CLOGGED SAS OR CESSPOOL.
The above system, according to our records has been in a failed state for more than two years.
Therefore, you are directed to hire a licensed Town of Barnstable septic system installer to sketch
a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The
State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice.
The septic system must be brought into compliance within (30) thirty days of your receipt of this
directive.
You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic'
system to prevent discharge of sewage or effluent into buildings, onto the surface of the ground, or
into surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court
of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
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Commonweotth of Massachusetts
Executive Office of Environmental Affairs
partment of 4
1; Environmental !Protection awEO
William F.weld
FEB 2 8 1997 °'
�or.me
Trudy Coxe
S.c•Ity EOFA TONMOFBARNSTA�
David B. Sttuhs fir' THDEP7
VCon.mia..on•,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
MAP# I / PART A
1'AR# O CERTIFICATION
Property Address: /`5 .9S ��iN �pTd/a 4 U� W 47 Ar A/
w_ love Address.of Owner:
Date of Inspection: A-/>t-V7 (If different)
Name of Insptctor. T 14£S Z S'TAiPS
Company Name, Address and telephone Number:
A & B Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reportsd below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
— Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_
Fails
lnspewtoea Signature: Date: p`Z '0 F7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspectiob. U 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B.C,or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Bj SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes
inspection.
Indicate yes,no,or not determined(Y.N,or ND). Describe basis of determination in all instances. If"not determined',explain why not)
TM septic tank U metal,cracked,structurally unsound,shows substantial infiltration or exfiltrotion, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(rsvited 11/0�/9S) �
OFN 0W Sp91 0 0000N M4$04chuaet 6 02108 0 FAX(617)SWI049 . TolephOnO(617)292-SSW
,t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM /
PART A
CERTIFICATION(oontinuod)
Property Address;-
Owner.
Date of lnspeoUon:
Bj SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is du to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if with approval of the Board of
Health):
broken Pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
— The system required pumping more than four times a year due to broken or rutted pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) FURTHER EVALUATION 1S REQUIRED BY THE BOARD OF HEALTI
Conditions exist which require further-evaluation by the Board of Hea h in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DET 1NES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEAL i AND SAFETY AND THE ENVIRONMENT-
— Cesspool or privy is within 50 feet of a surface w r
— Cesspool or privy is within 50 feet of a borderin vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF I LTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETMMINM THAT THE SYSTEM IS FUNCT NINO IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT
_. The system has a septic tank and so absorption system and is within 100 feet to a surface water supply or tributary to a
surface crater supply.
The system has a septic tank and il absorption system and is within a Zone I of a public water supply well.
The system bas a septic tank soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank , d&oil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well w .er analysis for ooliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that ility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(Mised 11/031 Z
►_
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
1 PART A
CERTIFICATION(continued)
roperty Address:
caner.
ate of Inspection:
l SYSTEM FALLS:
I have determined that the system violate#one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be neoessary to Correct the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
NDischarge or ponding of eflluent 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.
P i7'
Liquid depth in GON400is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Al Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Al Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
r Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a Cesspool or privy is within 60 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If the wgll 2ne#been analyzed to be acceptable,attach copy of vmU water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FALLS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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
th4 system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for Anther information.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addrow
Owner.
Date of Inspection:
Check if the-following have been done:
/No.n*
ping information was requested of the owner,occupant,and Board of Health.
of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
Zthat period. Large volumes,of water have not been introduced into the system recently or as part of this inspection.
Jt
bil plans have been obtained and examined. Note if they are not available with N/A.
VThe
he facility or dwelling was inspected for signs of sewage back-up.
system does not receive non-sanitary or industrial waste flow
V The site was inspected for signs of breakout.
JAII system components.'
19cluding the Soil Absorption System, have been located on the site.
JThe septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or
tow.material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
1Tu size and loatioa of the Soil Absorption System on the site has been determined based on existing information or
pprwimeted by nowintrusive methods.
V The facility owner(and occupants,if difforent from owner) were provided with information on the proper maintenance
P p pe of Sub-
Surfaoe Disposal System.
(revised 11/03/95)
I •
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION
p ss:arty Addre
caner:
ate sp of Inspection:
ow
CONDITIONS
party
flow:_ --sallons
umber of bedrooms: 3
umber of current relents•
arbage grinder(yes or no):NO
uadry connected to system(yps or no): 65
nal use(yes or no).—f 9
ater meter readings,if available: W 04, W 4-7-rR
date of occupancy:
OMMERCIAL INDUSTRIAL:
of establishment:
ign a ow:_Ssllonsiday
rease trap present:(yes or no)_
dustrial Waste Holding Tank present:(yes or no)_
on-sanitary waste discharged to the Title 5 system: (yes or no)_
ater meter readings,if available:
date of occupancy:
THER:(Describe)
date of occupancy:
GENERAJ,INFORMATION
PUMPING RECORDS and source of information:
N
System pumped as part of inspection: (yes or no)_£S
If yes,volume pumped: O O O ons
Reason for pumpinS J 5 tnJ /=vLL - /ii £v£L 1//° /�✓ T /,S-fe
TYPE q MTEM
Septic il absorption system
8iagle cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and sours of information:
Sewaga odors detected when arriving at the site:(yes or no) /V0
(revised 11103195) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address:
Owner.
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth below grade:,P
Material of construction:/concrete_metal_FRP other(explain)
Dimensions: D 00 £C T"
Sludge depth:_ 5
Distance from top of sludge to bottom of outlet tee or baffle: 4�/
Scum thickness: j a
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 7
Comments
(recommendation for pumping,oond�tion of inlet and outlet tees or bafner, depth of liquid level in re tion to outlet invert, structural ipt.egrity,
evidence of leakage,etc.) /�Nft A7_ LyoOC l�/N(� ,L f!/fL , /N A 1 T 7f £ JAI fT (o y f e 7 '
ELow RA F u v7` ,= £ T CaVF,f- 47'• jd TZ,w
GREASE TRAP._
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP —other(explain)
Dimensions:
Scum thickaw: -- - -
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
(revised 11103/95) 6
f.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner.
Date of Inspection:
GHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain)
Dimensions:
Capacity: ¢allons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.
DISTRIBUTION BOX._
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: /caM�ovtr.
hole if level and distribution is equal,evidence of soce of leakage into or out of boa,etc.)
PUMP CBAMBS&_
(locate on site plan)
Pumps is working order:(pa or no
Comments:
(note condition of pump r,condition of pumps and appurtenances,etc.
(rtvt 11103195) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontlnued)
Property Addrew
Owner.
Date of Inspeotion:
SOIL ABSORPTION SYSTEM (SAS):
(locate an site plak it pasible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type: leaching pits.number: �
leaching chambers,number:
leaching galleries.number.
leachiag treacbes,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Comments: (note condition of$oil,signs of hydraulic failure, levelof nding,condition of vegetation,etc.)
w�TP�£ ('£vf�i7' �! £.Cow d C/P/}1J� Coy£,e 7 '
Al 7 is J-,c
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of uolida layer.
Depth of scum layer:
Dimensions of ompool:
Materisk of construction- --
Indication of groundwater:
inflow(owpool must be pumped as part of inspection)
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 s4 a1PA of hydraulic failure,level of ponding,condition of vegetation,etc.)
r t ev1•
td 11/03145� 8
r
' v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Addnow
or.
ate of Iwpeotlon:
IQMH OF SEWAGE DISPOSAL SYSTEM:
iacb'A ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' p��M 57—
h
. nt1
h� 5g
DEPTH TO GROUNDWATER
0
Depth to Srouadwater. D•/o feet
method of determination or approximation:
ST iC t .�<T� i9�o of
NET !.✓A f,c. /9 r' /D•%�
(revised 11103/95) 9
TOWN OP BARNS-TABLE
LOCATION I.�5 �� SEWAGE # 0 - a 3Y-
VILLAGE W Q0�f C4-1 6-0"44 ASSESSOR'S MAP & LOT 1 7-0Y
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 16,00 �a
LEACHING FACILITY: (type) ��" ��" �`� (size) /— X 4V to
NO. OF BEDROOMS -�
BUILDER OR OWNER L✓(�(,✓ti_5
PERMTTDATE: 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 t
within 300 feet of leaching facility)J�'j Feet
Furnished by
�1� S�.z�er c�
I � O -
�h f
i � '
E
I
� 4
� i
i
h°� 5g
o ��:��,�
�, _ ��
a
--�.. _
9 3 --3 �r3
LO-CATION SEWAGE PERMIT NO.
/,57 A/%A/ 5' 2--
VILLAGE
I N S T A LLER'S NAME i ADDRESS
S UILDE R OR OWNER
DATE PERMIT ISSUED . �� �'
DATE . COMPLIANCE ISSUED , Z�--
�r
���,
.�
'� ..�;
,, �.y
�n �' o
��
-�,�!
�._____;
6-A -
No.....8.3-..._3y3 `� 'J F�s .... ...10.00»
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...................Town............OF...........Barnstable
ApphrFa#ion for Uhipaa ai Workii Tonstrnrtinn Famit
Application is hereby made for a Permit to Construct ( ) or Repair (x,) an Individual Sewage Disposal
System at:
....92668 ..............................................................................:...................
Location-Address or Lot No.
I�exir�e th._I�utl�ra.g................................-................................ 1 9 ••..Main S t.z West. Barnstable, 02668
Owner Address
A__&__B__CessDool__Service 128 Bishops Terrace, Hyannis, MA 02601
•---
Installer Address
UType of Building Size Lot...... ..................Sq. feet
Dwelling—No. of Bedrooms........................a_..........Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons...........2�.......... Showers — Cafeteria
Ga Other fixtures ..---•---------------------------••-••-•--•-•.
W Design Flow...........................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--.----..---_- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit..............--.... Depth to ground water........--........-----.
a -------••----•-------------•-••---------••-•-•-••----••---•---•.......••-•-•--•-••-•...:••------........-----••----••----.............•----.............-•-•-
0 Description of Soil........ and----••-------------------------••....--•--....----•••.----
x 3 = -
fr'°
,� -------- ---------------------•-------------------.....------------------........-••--••••---
w
_
ator 1 ll � of -- 1,000gallonsept - ,� wpli l --- -- -- - _. ._ -- --
stribuinboxand600 tn edeac-- pt
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to pl e the system in
operation until a Certificate of Complianc s een issued by the boars of 1
.---• -
5�24�83........
Sign --_-. •-- --•-••.......--- -.t-�.
Application Approved By............ .A/ = 5/ /83
Date
Application Disapproved for the following reasons:................................................................................................................
..................................
•-••-•--.......--•--`-•-••.............................................................................
•--•--•--......4••..--................ Dau---------.....
Perms No.... ..------`-�-13----------------------------- Issued--------5/----/V-3-----------•------------------.
Date
1
47—
No.--.g5.- ,� - _� �FEB............10»00^
THE COMMONWEALTH OF MASSACHUSETTS'
BOARD OF HEALTH
...........:....._Town.---.------..O F...........Barnstable........._...... ::::.
Appliration for Disposal Workii Toustrurtiun trntit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
xa...hie ..3AmetAbIg,..A 02669 -----------------------------------------------•-----..._..._...-•-------•----------•••-•-•-------
Location-Address 159.. Main S t., Jest or Lo No.
......._-•-------•----------- ---- arnstaht e, 0266$
a A--& B Cesspool Service 128 Bishops Terrace;d 5S nis, MA 02601
P............ .... .._.. ...
Installer Address
dType of Building Size Lot.................... ......Sq. feet
U Dwelling—No. of Bedrooms...............3 ..._.Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures .-----••------•-•---•--------•-•-•----_--•--
W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY..................................................................:....... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ------------••--•••-•••••--•-•--•--•--•---•----•-----•......................•-------•........................................................................
0 Description of Soil-•----sand---------------•----••••-••-•--•--•-------•--•-•-•••-•-•-•-----•--•-•••---•-•------------•-•--••••----------------•-•-••-•----------------------•-•-•-
V ..................................................................................'l ..-•-........................................................ .................................................
W -- -------- -- - •---•---------------••---- ---
x -- - - - - - � - � sta��at a�i ;0DQ__galTori��sep�i:c--tank,
V Nature of Repairs or Alterations s—Answer hen a plicable................. ----------------------
_-__-__---_---_---•--•---------..__...._.___.
distribution box, and 600 gallon, stonpe packed leach pig:
..-------•----------•--•------------------••----...---------------------------------...............-----.....---------------------------------------------------------------------------.._.._..._--•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitar Code— The undersigned further agrees not to pl Jacje the system in
operation until a Certificate of Compliance e e en issued by the board o �
Sign/ ��� % 5/ /83
�� 1 5 %83 ------
Application Approved By .................................................... Date
Application Disapproved.for the following reasons-------------•--------------••---------------------------------•-------------•--•-------------•-•------........._
24 8
Permit No .. Issued_.......................................................Dau
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................Town............OF.........Barnstable
.. .....................................................
Qlrrtifiratr of Tomplianrr
TI�IS I TO CERTIFY� TThat th II d d al Sewi e Dis osal Ste con uct ) or Repaired (X )
A & Cesspool Seim ce, �Z� R's osps' erra�e, �n'is, !A �01
bY-•-••-•-••-••-•--•-•--••-------•----...--•----•-•...................•--•--------•---...-•-••--�-{---- --------------------••--•--........................--•--...._........--•-•••-•-••--...-••-•--•-
at1595 Main St. , West Barnstable, MA 02�UJer— Kenneth Dudwig
--------------------------------------•----------•-------•--•----•--------------------------------------------------------••-----------------•--------_-_------.-------__----_---------------------
has been installed in accordance with the provisions of TIT -5 of The State Sanitary Co�t� cribed in the
application for Disposal Works Construction Permit No______ _____________'`...:..__________ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED,AS A GUARANTEE THAT THE
SYSTEM WIL)d FU CTION SATISFACTORY. �
DATE.:--�--------------------------••--••--•---••-------••-•• Inspector..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town.........OF........._._ Barnstable $ 10.00
8 - ....... .............
No._..3�................ Ui FEE........................
���a,�ttl nrk� ��an�trnrtuan lerntit
A & B Cesspool Service
Permission is hereby granted........................-----------------------------------------------------------------------------------------
...-•.........................
to Constru ll --or gg air x Indivi 1 Sevs=a a a1 �Vstem
1 M�1n REt �es� �arnsta011 I�Ag � --Kenneth Ludwig
atNo. ----- ...............
Street 83—_ Y^s7 5/2 /0
as shown on the application for Disposal Works Construction Permit No..................... Dated................................
._......_.
.......................................� ?-•y�,oard---of He_H`ealth----------------------------------------
/ ° )�
DATE......... .......----------------------
FORM 1255 A. M. SULKIN, INC., BOSTON -
it .. _ .
Loc&.Tl01�1 U0.
VILLAGE 7:7 � St' — —
IWSTRQLLER 5 ► &ME ADDRESS
BUILDER 'S 1.1 E ADDRESS
DQTE PERMIT ISSUED
DATE COMPLI A,NICE ISSUED ; — ��
VAI4�a'. Pao, .
1
S
�eao tea !
b7```
No.. --J Ymiic...... -!...............
1{-• THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..._.......OF..... ....................
Appliration for Diopos tl Works Tons#rudion Vrrufit
Application is hereby made for a Permit to Construct ( ) or Repair (L,-'an Individual Sewage Disposal
Syst at
--•-•- .' --------------------------------------- ..........................-........................
-----
-----------------------------------------
.�..Lo ion:Address or Lot No.
........ --------•---------------------
Owner/ Address
Installer Address
Q Type of Building Size Lot________________________---Sq. feet
U Dwelling—No. of Bedrooms-------------------6 _---_Expansion Attic ( ) Garbage Grinder ( )
a, Other—Type of Building _ 1 No. of persons---------------------------- Showers ( ) Cafeteria ( )
Q' Other fixtures __-_-------------------------- - -
W Design Flow-------------------------------------_------gallons per person per day. Total daily flow-------_______-__---___-_.....;,;...___._..ga
llons.
ons.
WSeptic Tank—Liquid capacity------------gallons Length-_------------ Width.--------------- Diameter-_-._ ll__.-_.___- Dept ___-.--------- �
xDisposal Trench—No- ____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area------- ----------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------- --------_ .......................... ------------------------_. Date--------.-----------------------------..
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_..-_--..-._--.--._..._-
L14 Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water-----..__.___-_--___.
P+
O Description of Soil-_ _ . . .
x
U --------------•---------------------- ---•----------------------------------------------------------------------------------------------------------- ................ --------------------------------
W ----------------------------------------------------------------------------------------------------------------------------
UNature of ep- s or Alteratio —Answer hen pplicable.__.. c�! / alb -
-- ---—;, ----V---`1Z------- ----------------------------------------------------------
greement:
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 een issue by he board of hea I.
ti.
Sign '`^ ._._._..... _ 7 -------
Date
Application Approved By________...
Date
Application Disapproved for the following reasons:............................... ---------------------------------------------------------------------
...
p
-----=•------------------------------------------------------------------------------------------------- ------------------ --------------------------------
`. / Date
{ Permit No. Issued1 ----
Dat --
No._ ..... ........... Fizs. 4;?��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Alrpliratiaaan -for Di!iVaaiittl lVarkii CJumitt rliaaln Pprutil
Application is hereby made for a Permit to Construct ( ) or Repair ( G}!an Individual Sewage-Disposal
1
Sysim at----- 1 D ----•-----------------_•----------.•..---•----•--••-----------.-------•---•--••--------..
///� i7 -.tion-Ad ess or Lot No.
ner 7 Address
:.
p Installer Address
Q ype of Building Size Lot----------------------------Sq. feet
rJ Dwelling—No. of Bedrooms_______________________________ _ _____Expansion Attic ( ) Garbage Grinder ( )
a YP g p Showers ( ) — Cafeteria ( )
' Other—Type of Building ............................ No. of ersons.______.__.____.__._...__._.
a Other fixtures --•---------•••-•••-------••-• -
W Design Flow_________________________-___-____________--gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter__-___-__._-_- Depth._____.-_-.-.
x Disposal Trench—No_____________________ Width.................... Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No---------_--------- Diameter___-_--__-_-__-__-__ Depth below inlet.................... Total leaching area-.-_--.-----..__-_sq. it.
Z Other Distribution box ( ) Dosing tank ( )
~" "t Percolation Test Results Performed by......------------........................................................ Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit-----_.............. Depth to ground water.....................
44 Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
- 4
0 Description of Soil--.._.
U - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W -----------------------------------------------------------------------------------------------------------------------------
- --- -- ------ ---- --------------------
V Nature of R airs or Alterations—Answ r wh n applicable. -- -�-------/-�- ----
x
------- ....
reem`ent
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I 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 t board of healthfi
-••• ---- - -- - - ------------------------
Date
A lication A roved B /V44L
Date
Application Disapproved for the following reasons:--••-------------------•--------••--•--•--------....._-•-•-•-•--••---•-•--•--•-••------------•-•---••--•••-•--•-
...................................•--••-----•------•---•--•--•-•-•-----------------••---•----•_--
Date
Permit No......................................................... Issued.--_ . _
Date
1 '
THE COMMONWEALTH OF MASSACHUSETTS
r eBOARD OF HEALT
(Iritifirate of (taampliaurr
T IS IS To C TIFY hat the, Individual Se�Zftge Dispo al System constructed ( ) or Repaired (�
. -- -
at-- Inst �
has been installed in accordance with the provisi of Article XI of The State Sanittrt+y Xd/, c lsF�ilbed in the
application for Disposal Works Construction Permit.No_________________________________________ dated................................................
THE ISSUANCE OF THI CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT THE
SYSTEM W L F NCTION ATISFACTORY.
DATE
AT✓.a„:-1 t b �..•.a=.Y:'fi'"ra.'+.;se�s.,.,t_'--. .�... asgrtC` _.-u.+.....�_� rrs� I.j'ns.p4a^ercotvoarw` -� . ..-• ,, -
. •---
'
.s,�.�f�.f, •x..�
THE COMMONWEALTH OF MASSACHUSETTS
ar
BOARD
.. OF HEALT
.. .10,elA. .......O F.........1
No......................... FEE....4�............
Permission is hereby grante ..... • "
to Construct ( ) ;or Repair In vidual Sewage Disposal System
atNo------------------ ' Str
as shown on,the ,ppli tion for Disposal Works Constr n to _........r:..............................
I ,qA
T Board o ealth
DATE...................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r ,
350 MAIN STREET TEL: (508)775-2800
WEST YARMOUTH MA 02673 (800)698-3993
FAX:(508)778-9628
Septic Service Mechanical Services
Pumping & 6" Heating & Plumbing
Installation Fire Sprinklers
Since 1930
March 22, 2000
Town Of Barnstable
Board of Health
Attn: Mr. Glen Harrington
367 Main Street
Hyannis, MA 02601
RE: 1595 Main Street, West Barnstable
Dear Glen,
A & B Canco, representative of Mr. James D. Sears, inspected the sub-surface waste water
disposal system for Mr. and Mrs. Kenneth Ludwig at 1595 Main Street, West Barnstable, MA on
February 21, 1997.
His inspection revealed a problem, the liquid depth in the leaching pit was less than 6" below
invert. His report noted this condition and produced a failed condition. A copy of this report
was mailed to the Barnstable Health Department and the owners.
Mr. Ludwig called A & B Canco upon receiving the failed report and requested a supervisor to
review the findings due to the limited use of the dwelling at that time.
I met with Mr. Ludwig and confirmed the findings of James Sears, the inspector. A check of all
plumbing fixtures was performed and a bypass valve on the domestic well water system was
found defective and in full flow bypassing water directly into the drain pipe.
A repair was made to the valve to correct the bypass which was allowing hundreds of gallons
constantly to flow into the septic system. The system was pumped at this time. After the
repair to the domestic water system, I re-inspected the system and found the leach chamber
had dropped to within 10" of the bottom under normal household usage.
I produced a revised report on April 1, 1997 with notes explaining the problems found and the
current operating levels. At that time I placed a call to the Health Department and explained
the reason for the second report. I was advised to send a copy to the health office to be
reviewed.
The system was re-inspected September 2, 1999 by myself and found to be in good working
order. On January 20, 2000, Mr. and Mrs. Ludwig received a registered letter requesting the
septic system be repaired. With this explanation and history of site will allow the Health
Department to rescind the order of compliance.
derstanding,
Richard K. Cannon
RKC:akb
CoMMONW1iAlA'11 OF MASSAC USEA'�'s
Gu,nvi; ovvicr Ur CNVJRONM.tN'1'A1., A. rAiit.s
�)11'Ait'1'Mt N'i' 01 :NWRONWN'i'AI., P.RQ''i; TIUN
� zi, ON> WIN'1'fit STREET, I10S1'ON MA (1'L10(4 (617) 297.-ri�i0t1
350 MAIN STREE i
WEST YARMOUiI 1, MA TRUDY CoxF.
C 503-775-2800 Secrernry
ARGEO PAUL C(;I.LUC(,'I DAVID 11. STRUHS
Crnnmiseionrr
Go�rrnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP 197 PAR 044
PROPERTY ADDRESS: 1595 MAIN ST.,WEST BARNSTABLE ADDRESS OF OWNER:
DATE OF INSPECTION: AUGUST 24, 1999 KEN LUDWIG
NAME OF INSPECTOR : RICHARD K. CANNON
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A& B Canco
MAILING ADDRESS: 350 Main Street,Wes(Yannouth;MA 02673
TELEPHONE NUMBER: 508)775-2500
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and Iha((he information reported below is(rue,
accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The syslern:
X PASSES
CONDI HONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
TY
FAILS
INSPECTORS SIGNATURE: \— I� DATE: '
The system Inspector shall submit a copy of this inspection report to the Approving Authorily(Board of Health or DEP) within thirty(30)
days or 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 submil the report to the appropriate regional office of the Department of Environrnenlal Protection. The original
should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
NOTES AND COMMENTS:
SITE OVER ALL PASSES, INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT TINE TIME
OF THE INSPECTION.THERE 15 NO GUARANTEE ON 1 HE L)r E OF TIME SYSTEM.
revised 9/2/98
SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES: YES
have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMN
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
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.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exhitration,or tank is failure Is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board or Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four 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
revised 9/2/98
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
FART A
CERTIFICAtION(continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 Welland 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 AND
SAFETY AND THE 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 soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil.absorption syslern and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis 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 and is equal to or less than 5 ppm. Method
used to determine distance _(approximation not valid).
3) OTHER
revised 9/2/98 3
SUBSURFACE SEWAGE lDI§P0sAL SYSTEM INSPECTION FORM
PARR A
CERTIFICATION(continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
D] SYSTEM FAILS: N/A
You must indicate either"Yes"or"No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. The basis for this determination is Identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or pending of effluent to the surtace of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day now
Required purnping more than 4 times in the last year NOT due to clogged or obstructed pipets)
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy Is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable,attach
copy of well water analysis for colifonn bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 god or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
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
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X - None of the system components have been pumped for at least two weeks and the system
Has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with NIA.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X_ The septic lank manholes were uncovered,opened,and the Interior of the septic lank was
inspected for condition of baffles or lees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information. Ex.Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)115.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1595 MAIN STREET,WEST BARNSTABLE
Owner: LUDWIG, KEN
Date of Inspection: APRIL 1, 1997
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 3 Number of bedrooms(actual):
Total DESIGN flow
Number of current residents: 2
Garbage grinder(yes or no): YES
Laundry(separate system) (yes or no): If yes,separate inspection required
Laundry system inspected(yes or no):
Seasonal use(yes or no) NO
Water meter readings,if available(last two(2)year usage(gpd): WELL WATER
Sump Pump(yes or no):
Last date of occupancy:
COM M ERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
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 occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no) YES
If yes,volume pumped: 2,000 gallons
Reason for pumping MAINTENANCE,DEFECTIVE WATER SOFTENER BYPASS VALVE FLOODED SYSTEM
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
1983 PERMIT#83-343
Sewage odors detected when arriving at the site:(yes or no) - NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction cast iron 40 PVC other(explain)
Distance from private water supply well or suction line _
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: YES
(Locale on site plan)
Depth below grade: 28"
Material of construction X concrete _ metal Fiberglass _ Polyethylene other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 1,000 GALLON _
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 31
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How dimensions were determined TAPE
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,INLET TEE,OUTLET TEE
INLET COVER 7"BELOW,OUTLET COVER 28"BELOW GRADE --
GREASE TRAP: N/A
(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:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or 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/day
Alarm present
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: NIA
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARt C
SYSTEM INFORMATION (continued)
Property Address: 1595 MAIN ST., WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
SOIL ABSORPTION SYSTEM (SAS): YES
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methpds)
If not located, explain:
Type:
Leaching pits,number: 1
Leaching chambers,number:
Leaching galleries,number:
j Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegelallon,etc.)
4'PRE CAST PIT 4'BELOW GRADE,COVER 7"BELOW GRADE
WATER LEVEL IN PIT 10"
NO SIGN OF OVERLOADING OR HIGH WATER MARK _
CESSPOOLS: N/A
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scurn layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(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.)
revised 9/2/98 9
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1595 MAIN ST., WEST BARNS TABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
SKE7CH OF SEWAGE DISPOSAL SYS 1 EM:
�tl(� include lies lo_al least two permanent references landmarks or benclnnarhs
locale all wells within 100 (locale where public water supply comes into house)
U
lu
1 f r7
U
0
revised 9/2/98 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1595 MAIN ST., WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
NRCS Report nam-
Soil Type — ------ -----� —..-------
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow _— Moderate _ _ Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater 10 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
X Observation of Site-observation hole,
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavaFors,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
NOTE: HAND DUG TEST HOLE
TEST HOLE NOTED ON PAGE 10
revised 9/2/98 11
a
COmrnonwWh Of M=Ochuseffs
Executive Office Of Envhonmenfol Affoics
Department of
t
15Q111sm F.Weld ifof Protection
cw.mpl
Trudy Coxe ca=
S.c.a,y.EOEA
D.v1d S. St.uh: 350 MAIN ST, W. YARMOUTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP# 197
PAR# 044
PROPERTY ADDRESS:1595 Main St. W. Barnstable ADDRESS OF OWNER:
DATE OF INSPECTION:April 1, 1997 Ludwig, Ken
NAME OF INSPECTOR:Richard K. Cannon
COMPANY NAME,ADDRESS AND TELEPHONE NUMBER:
A&B CANCO, 350 MAIN STREET, WEST YARMOUTH, MA 02673 (508)775-2800
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 inspection. The inspection was performed based on
my training and experience'in the proper function and maintenance of on-site sewage disposal systems. The
system:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
Inspector's Signature: SLS of Date: c, q i
The system Inspector shall submit a copy this inspection report to the Approving Authority within thirty(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 Department of
Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving
authority. Inspector based on condition of system at time of inspection,there is no guarantee of life span of
system.
INSPECTION SUMMARY:
Check A, B, or C
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
N/A One or more system components need to be replaced or repaired. The system, upon completion of the
replacement or repair, passes inspection.
Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If
not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,
_ or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced
with a conforming septic tank as approved by the Board of Health.
1 (REVISED 11-03-95)
One Winter Street Boston, Massachusetts 02108 Fax(617)556-1049 Phone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
Property Address: 1595 Main Street West Barnstable
Owner: Ludwig, Ken
Date of Inspection: April 1, 1997
B] SYSTEM CONDITIONALLY PASSES (continued)
_N/A_ Sewage backup or breakout or high static water level observed in the distribution box is due to
broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system
will pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
_N/A_ The system required pumping more than four 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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_N/A_ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC
HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A
MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public
water supply well.
The system has a septic tank and soil absorption within 50 feet of a private water supply
well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50
feet or more from a private water supply well, unless a well water analysis for coliform bacterial
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.
3) OTHER
. 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1595 Main Street West Barnstable
Owner: Ludwig, Ken
Date of Inspection: April 1, 1997
D]SYSTEM FAILS:
N I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or
cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
N/A Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool.
N Liquid depth in pit is less than 6" below invert or available volume is less than 1/2 day
flow.
N Required pumping more than 4 times in the last year NOT due to clogged or obstructed
PIPe(s)•
Number of times pumped
N Any portion of the Soil Absorption System, cesspool or privy is below the high
groundwater elevation.
N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary
to a surface water supply.
N Any portion of a cesspool or privy is within a Zone I of a public well.
N Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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. If the well has been
analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile
organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the
system is a significant threat to public health and safety and the environment because one or
more of the following conditions exits:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of
the Department for further information.
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1595 Main Street West Barnstable
Owner: Ludwig, Ken
Date of Inspection: April 1, 1997
Check if the following have been done:
X Pumping information was requested of the owner, occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the
system has been receiving normal flow rates during that period. Large volumes of
water have not been introduced into the system recently or as part of this inspection **
X As bullet plans have been obtained and examined. Note if they are not available
with N/A
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow
X The site was inspected for signs of breakout.
X All system components, including the Soil Absorption System, have been located
on the site.
X The septic tank manholes were uncovered, opened, and the interior of the septic
tank was inspected for condition of baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been
determined based on existing information or approximated by non-intrusive
methods.
X The facility owner(and occupants, if different from owner) were provided with
information on the proper maintenance of Sub-Surface Disposal System.
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1595 Main Street West Barnstable
Owner: Ludwig, Ken
Date of Inspection: April 1, 1997
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: gallons
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): YES
Laundry connected to system (yes or no): NO
Seasonal use (yes or no): NO
Water meter readings, if available WELL WATER
Last date occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment: N/A
Design flow: gallons/day
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharge to the Title 5 system:(yes or no)
Water meter readings, if available:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no) YES
If yes, volume pumped: 2,000 gallons
Reason for pumping MAINTENANCE , DEFECTIVE WATER SOFTNER BYPASS VALVE
FLOODED.-SYSTEM
TYPE OF SYSTEM
X Septic tank/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection recods, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
1983 PERMIT#83-343
Sewage odors detected when arriving at the site:(yes or no) NO
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1595 Main Street West Barnstable
Owner: Ludwig, Ken
Date of Inspection: April 1, 1997
SEPTIC TANK:_X_
(locate on site plan)
Depth below grade: 28"
Material of construction: X concrete metal FRP other(explain)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 29
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
Comments:
(recommendation for pumping, condition of inlet and outlet tees ;or baffles, depth of liquid level in
relation to outlet invert, structural integrity, evidence of leakage, etc.) TANK AT WORKING LEVEL, .
INLET TEE, INLET COVER 7" BELOW GRADE, OUTLET COVER 28" BELOW GRADE
GREASE TRAP:-
NA-(locate on site plan)
Depth below grade:
Material of construciton: concrete metal FRP 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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation
to outlet invert, structural integrity, evidence of leakage, etc.)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1595 Main Street West Barnstable
Owner: Ludwig, Ken
Date of Inspection: April 1, 1997
TIGHT OR HOLDING TANK:-
N/A-(locate on site plan)
Depth below grade:
Material of construciton: concrete metal FRP other(explain
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: N/A
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of
box, etc.)
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(yes or no)
(note condition of pump chamber condition of pumps and appurtenances, etc.)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1595 Main Street West Barnstable
Owner: Ludwig, Ken
Date of Inspection: April 1, 1997
SOIL ABSORPTION SYSTEM (SAS):_X_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive
methods)
If not determined to be present, explain:
Type:
leaching pits, number: 1
leaching chambers, number:
leaching galleys, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)4' PRECAST PIT, 4' BELOW GRADE COVER 7" BELOW GRADE WATER LEVEL IN PIT 6"
CESSPOOLS: N/A
(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 cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:(note condition of soil, signs of hydraulic faiure, level of ponding, condition of vegetation, etc)
PRIVY: N/A
(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.)
8
w .
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1595 Main Street West Barnstable
J Owner: Ludwig, Ken
Date of Inspection: April 1, 1997
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR
BENCHMARKS
LOCATE ALL WELLS WITHIN 100'
Vt.
O
LLJ
,o g
7 3
o
0
DEPTH TO GROUNDWATER
Depth to groundwater: 10' feet
method of determination or approximation: HAND DUG TEST HOLE AS NOTED ABOVE WATER
TABLE AT TEN FEET
9
Yea'.,
I
- (;UMMUNWLAL'I'lt OF MASSACI4US�'I"1'S
— _
_- EX.ECU'I'IVE OFFICE OF CNVIRONMENTM, .AFFAI '*
Utit'AR'I'M1sIV'I' OF ENVIIZONMJWI'AL PnO11.=LC O)N, �
ONE WINTER STREET, BOSTON MA 02108 (617) 292.-5500 �, t
Z y (F.
350 MAIN STREET . r ,l � RUDY� XF,
&� WEST YARMOUTH, MA
S.508-775-2800. ~� A r tnry
ARGEO PAUL CELLUCCI ID T3: 'U1IS
Con gioner
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR qb
PART A
CERTIFICATION t�
MAP 197 PAR 044
PROPERTY ADDRESS: 1595 MAIN ST.,WEST BARNSTABLE ADDRESS OF OWNER:
DATE OF INSPECTION: AUGUST 24, 1999 KEN LUDWIG
NAME OF INSPECTOR : RICHARD K. CANNON
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A 8 B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 _
TELEPHONE NUMBER: (508)775-2800
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 inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: �k DATE: IT
The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department or Environmental Protection. The original
should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
NOTES AND COMMENTS:
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT T14E TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
INSPECTION SUMMARY: Check A, B, C, orD:
A] SYSTEM PASSES: YES
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
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.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
iinspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four 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
revised 9/2/98 2
SUBSURFACE SEWAGE DISPOSL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 AND
SAFETY AND THE 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 soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis 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 and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 3
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
D]SYSTEM FAILS: N/A
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
15.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
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
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 13
CHECKLIST
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X- None of the system components have been pumped for at least two weeks and the system
Has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information.Ex. Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)11 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
FLOW CONDITIONS
RESIDENTIAL: YES
Design flow: 330 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 3 Number of bedrooms(actual): 3
Total DESIGN flow
Number of current residents: 2
Garbage grinder(yes or no): YES
Laundry(separate system) (yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):
Seasonal use(yes or no)
Water meter readings,if available(last two(2)year usage(gpd): WELL WATER
Sump Pump(yes or no): —�
Last date of occupancy:
COMMERCIAL/INDUSTRIAL: N/A
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
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 occupancy:
OTHER:(Describe)
Last date of occupancy: ----
GENERAL INFORMATION
PUMPING RECORDS and source of information:
APRIL A997
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: _ gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known)and source of information:
1983 PERMIT#83-343
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line _
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: YES
(Locate on site plan)
Depth below grade: 28"
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 1,000 GALLON
Sludge depth: V,
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: V
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How dimensions were determined TAPE
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,INLET TEE,OUTLET TEE
INLET COVER 7"BELOW,OUTLET COVER 28"BELOW GRADE
GREASE TRAP: N/A
(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:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1595 MAIN ST.,WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or 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/day
Alarm present
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: N/A
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1595 MAIN ST., WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
SOIL ABSORPTION SYSTEM (SAS): YES
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 1
Leaching chambers,number:
- Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions: _
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
4'PRE CAST PIT 4'BELOW GRADE,COVER 7"BELOW GRADE
WATER LEVEL IN PIT 19'
NO SIGN OF OVERLOADING OR HIGH WATER MARK
CESSPOOLS: N/A
(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(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(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.)
revised 9/2/98 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1595 MAIN ST., WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
ALL include lies to at least Iwo Permanent references landmarks or benchmarks
locale all wells wilhh 100'(locale where Public water supply comes into house)
O
,jrT S'�E
u
ay_Y a7 c
0
revised 9/2/98 10
f ,
M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1595 MAIN ST., WEST BARNSTABLE
Owner: KEN LUDWIG
Date of Inspection: AUGUST 24, 1999
NRCS Report name ,
Soil Type ----+
Typical depth to groundwater ------""
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate _ Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater 10 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
X Observation of Site-observation hole,
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
NOTE: HAND DUG TEST HOLE
TEST HOLE NOTED ON PAGE 10
revised 9/2/98 11
ASSESSORS MAP : . 197TEST HOLE LOGS _. oT�?
PARCEL : � 'y'� . .. .
\ FLOOD ZONE : .�/OT �p�L/G�gBG SOIL EVALUATOR : ) \ I
WITNESS : l� 1` �4R. I - .G _
C` REFERENCE: DE5ED a�� DATE: l�l�C- Z I �� �n i I � (�V ' � 5 �I�G-4Z I �' -} laC k1.17(J'
PERCOLATION RATE : 4 Z MIA ! � - �_ �cPT+Ic,
41 ,
TH- I — — TH_2.
�n
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LOCATION MAP Lo� ` a
1 �I �b - ►rj, c --1 b-p ln-1 ,r 4�,n Z,471,j
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Zz SEPT I C; SYSTEM DESIGN
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FMATE
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Ll
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10N/ Ic
USE � )� GALLON SEP iC TANK
SO 1 L AE SORPT I ON SYSTEM
Y
it r
S' D AREA:( + 1,5�`,I �� t + "q,5+8,5
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;
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LOCATION :I ON : I� S �UT��. 4—
_ PREPARED FOR : `}-{F
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SCALE : r
DAV I D B . MASON DATE :
DBC ENVIRONMENTAL DESIGNS
EAST SANDWICH . MA
DATE HEALTH AGENT. ( 508 ) 833- 2 177
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