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Home My WebLink About1912 MAIN ST./RTE 6A(W.BARN.) - Health 1912 MAIN STREET/RTE 6A F West Barnstable A= 216 -034 m o Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r-z G M 1912 Main Street(Route 6A) cI Property Address r�a a� Thomas Tracy Owner Owner's Name L; information is tr,=° required for every West Barnstable Ma 02668 June 18 2Q18 page. Cityrrown State Zip Code Date of Inspection r%j Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, v f� use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. Excavation Company � Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 21h June-18-2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 40 M VS Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is required for every west Barnstable Ma 02668 June 18th 2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is required for every West Barnstable Ma 02668 June 18t"2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is West Barnstable Ma 02668 June 18th required for every 2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) I System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is West Barnstable Ma 02668 June 18t" required for every 2018 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is West Barnstable Ma 02668 June 181h required for every 2018 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is required for every West Barnstable Ma 02668 June 18t"2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gp ))� Detail: ****WELL WATER**** Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is required for every West Barnstable Ma 02668 June 18t"2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner-date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is West Barnstable Ma 02668 June 18th required for every 2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Permit dated 3-14-95 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1'2"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallons Sludge depth: 2" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is West Barnstable Ma 02668 June 18t"required for every 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owners Name information is West Barnstable Ma 02668 June 18th required for every 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is required for every West Barnstable Ma 02668 June 18t"2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is West Barnstable Ma 02668 June 18t" required for every 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching had 1' of standing water when viewed with a stain line just over half way up the pit from the bottom. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is required for every West Barnstable Ma 02668 June 18t"2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is required for every West Barnstable Ma 02668 June 18"'2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C Garage A B 103'from well to 00 2 0 Al-18' 81-22' 132-49' C2-51' 133-58' C3-60' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is required for every West Barnstable Ma 02668 June 18t1'2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW @ 12' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Information on file with the Board of Health ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Information at the Board of Health showed no groundwater at 12'. Two previous inspection reports were on file. A hand hole was augured to 12' with no ground water encountered and another where USGS TOPO maps and charts showed ground water to be over 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1912 Main Street(Route 6A) Property Address Thomas Tracy Owner Owner's Name information is required for every West Barnstable Ma 02668 June 18t"2018. page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I 1 Massachusetts Department of Environmental Protection I I c\ Bureau of Resource Protection Well Completion Reports Well Driller Please specify work performed: Address at well location: Decommissioned Street Number: Street Name: 1912 MAIN ST. Please specify well type: Building Lot#: Assessor's Map#: Domestic �i Assessor's Lot#: ZIP Code: Number Of Wells: City/Town: Well Location BARNSTABLE In public right-of-way: GPS C Yes C' No North: West: 41.69654 70.34426 Subdivision/Property/Description: Mailing Address: r click here if same as well location addres Property Owner: Street Number: Street Name: AMY JO JOHNSON 3 VIOLET AVE City/Town: State: Engineering Firm: --Choose City--- ZIP Code: Board of health permit obtained: r. Yes �`Not Required Permit Number: Date Issued: W2016 008 04/22/2016 t4 . i Massachusetts Department of Environmental Protection ?- Bureau of Resource Protection—Well Driller Program Well Completion Reports(Decommission) Well Driller - Decommission Form WELL INFORMATION Date Decommissioned 05/26/2016 ____--] Depth of Decommissioned Well 16 ADDITIONAL INFORMATION(IF AVAILABLE) Original WCR#for Decommissioned Well Well ended in formation type t: Overburden =Bedrock Was a new well drilled? Ye WCR#for New Well CASING Casing Type Casing Diameter 48 Was casing ripped or Was Casingleft in lace. Yes No r r. place? perforated? Yes No Were obstructions left in the well? r'Yes r No If yes,what type? I Choose Description - Surface Seal Type G�f' DECOMMISSIONING MATERIAL From It To It Water (BGS) (BGS) Material 1 Weight Material 2 Weight (gat) Batches Method Of Place I� 16 �nd 120 Concrete__...___ 'a 150 Gravity __._ WATER LEVEL Date Measured Static Depth BGS(ft) Flovuing Rate(gpm) 04/22/2016 116 � COMMENTS DUG WELL,4'DIA.X 16'DEEP LOCATED IN BASEMENT OF HOUSE.WELL LINED WITH PRECAST CONCRETE BLOCKS,NO= BOTTOM OF WELL WAS DRY.MINOR AMOUNT OF WOOD DEBRIS IN BOTTOM NOT REMOVED PRIOR TO FILLING DUE TO SAFETY HAZARD.NOTE:IGNORE CASING MATERIAL TYPE ABOVE.NO CHOICE AVAILABLE FOR CONC.BLK r e Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(Decommission) t4 WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision, according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. Monitoring[M] Supervising Driller PETERSO Driller R.PETERSON Registration# 786 RONALD, ATLANTIC WELL Signature Date Job Complete Firm DRILLING, INC. Rig Permit# 05/26/2016 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. I ' BOARD OF HEALTH TOWN OF BARNSTABL, E lVerr Br5truction Perruit No.�� 'O'D Fee--At-------------- Permission is hereby granted CLC Wit'------- .... -........... ---....... _ to destruct an Individual Well at No.--- 2--- - ° ---_-! ° !�`� --- -- - - Street as shown on the application for a Well Destruction Permit No.--1��1_-� -- Dated------ --- --__—�_+-----___._--�---------------------------- Board of Health DATE —- __. '-' - -� ----------------------------- r Town of Barnstable Regulatory Services D.e arfinent p P . rFD MA'I Public Health Division 200 Main Street,Hyannis MA 0260.1 Office: 508-862-4644 Richard Scab,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6,'2007 Rev. 7/6/15 DEADLINES TO REPAIRTAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe, ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS of cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of-the cesspool within'a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water.quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) o Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) BOTHER Repair deadline: V—e&t WSEPTICOEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts �h �`'✓ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 1912 Main Street/ Route 6a M J7 Property Address 4j Amy Jo-Johnson Owner Owner's Name C" information is West Barnstable Ma 02668 3-16-16 required for every page. City/Town State Zip Code Date of Inspection N R9 t-► Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation ray Company Name 374 Route 130 Company Address m Sandwich Ma 02563 _ City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-16-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts H, w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1912 Main Street/Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank pis metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street/'Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): D-Box was broken on one side after being hit by gas line installation. D-box will need to be replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 L c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street/Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is West Barnstable Ma 02668 3-16-16 required for every — page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street/Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is'within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street/Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street/ Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See Below 9 ( Y 9 (9P ))� Detail: WELL WATER" Sump pump? ❑ Yes ® No Last date of occupancy: 1 week ago Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1912 Main Street/Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pump unknown Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 1912 Main Street; Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 3-15-95 (Plan date) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain).- Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallons Sludge depth: 5 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �., 1912 Main Street/Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is West Barnstable Ma 02668 3-16-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date tins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street/ Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 1912 Main Street/ Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box was found to be broken. D-box will need to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 1912 Main Street/Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 (6'x6') ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Pit was full. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth'—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Main Street Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1912 Main Street/ Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately DRIVEWAY A FRONT A B C 2 18r 12' _ . i . � 3 58, 6 ' MAIN STRE.ET t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f _ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1912 Main StreeJ Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every West Barnstable Ma 02668 3-16-16 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 3-15-95 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1912 Main Street/Route 6a Property Address Amy Jo-Johnson Owner Owner's Name information is required for every west Barnstable Ma 02668 3-16-16 page. CityTTown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I Commonwealth of Massachusetts u Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Route 6a Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the computer, r,use 1. Inspector: � only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code 1 (508)477-8877 S14454 r Telephone Number License Number B. Certification I certify that..I have personally inspected the sewage disposal system at this address,and that the information reported below is true, accurate and complete as of the time of the inspection. TheinspeDlon was performed based on my training and experience in the proper function and maiptenance of on Me sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of- Title 5 (310 CMR 15.000).The system: -, ❑ Passes ® Conditionally Passes ❑ Fails •R ❑ Needs Further Evaluation by the Local Approving Authority c, r-n lz, 2/18/2011 Inspecto s Slgna re Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspe ',on. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of.17 s • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 1912 Route 6a Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: J B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I f Commonwealth of Massachusetts W Title 5 Official Inspection Form VA Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Route 6a M Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ® broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Cap is missing on clean out.Sanitary tee is missing on outlet end of septic tank. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require-further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Route 6a M yye e Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or."No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow , t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M -1912 Route 6a Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 F Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1912 Route 6a Property Address Amy Johnson Owner Owner's Name information is W Barnstable Ma. 02668 2/18/2011 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1912 Route 6a Property Address Amy Johnson . Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 _ every page. City/Town State Zip Code Date of Inspection D. System Information F Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well g ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ .No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Route 6a ,M Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 151ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Route 6a Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10, feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence'of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 411 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Route 6a M Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump every two years.lnlet tee is in place.Outlet tee is missing.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts • W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 1912 Route 6a Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of Inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 1912 Route 6a M Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Route 6a M Property Address Amy Johnson Owner Owner's Name information is required for W,garnstable Ma. 02668 2/18/2011 every.page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Water level was 16" below invert at time of inspection with no stain line higher. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 IL _. Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1912 Route 6a M Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System - f Parcel Viewer Custom Map Abutters Map Size ® Ell Zoom Out In I ��. I. t-M 3 58 6 U R- q i ♦• yfJ"Y��y, +yt• l"7�-GIs.t t J✓ . rG '0.Feet ;i Set Scale 1" _+2p I Aerial Photos _* I MAP DISCLAIMER r.—,rinht 9MF-901n Tnurn of R-Onhin hAA All rinhtc rccnnr. x� • e, 'xf I http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=216034&mapparback= 2/23/2011 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 1912 Route 6a Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 45' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate #2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 t '. Commonwealth of Massachusetts W Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1912 Route 6a Property Address Amy Johnson Owner Owner's Name information is required for W Barnstable Ma. 02668 2/18/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® .Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 AsBuilt Page 1 of 1 r± r TOWN OF BARNSTABLE LOCATION 19/.;k-, tZ+ SEWAGE VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.Co,� LJ Ev��-_t'ps gQs ScZ'y77,7 r a SEPTIC TANK renA�rry n'�.6t ` FQ Q, (&iw.) NO.OF BEDROOMS OWNER �w�v T��w�o v` PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY _._..._ ..__.......................... .._._._,_.. ....— —.,_..—.- i — �— o VIM s IL 0 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=216034&seq=2 4/25/2016 Town of Barnstable Barnstable hAxl Regulatory Services Department V p � ' Public Health Division m MBA 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Certified Mail# 7015 1520 0001 2273 3265 March 31, 2016 Amy Johnson 21031 Ventura Blvd#1000 Woodland Hills, CA 91364 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1912 Main Street/Route 6A,West Barnstable,MA was last inspected on 3/16/2016,by Matthew Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Need to replace broken distribution-box You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF TH BOARD OF HEALTH Thomas McKean, R.S., CHO �� G" Agent of the Board of Health 0 v 6 Q:\SEPTIC\CONDITIONALLY Passes Ltr\1912 Main Street/Route 6A 'own of Barnstable Barnstable kriftid _. .� Regulatory Services Department Q P °'"M 639` Public Health Division on m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0001 2273 3265 March 312016 Amy J. Johnson 1912 Main Street/Route 6A West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1912 Main Street/Route/6A,West Barnstable,MA was last inspected on 3/16/2016,by Matthew Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Need to replace broken Distribution-box You are orderdd to repair/replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Conditionally Passes Ltr\60 Madison Ave Cent Mar/2016 L `` ti No.70 6 - O Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS R plication for ' 5 08a' 6pstem Construction Permit —D 130 V Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) []Complete System Aindividual Components Location � of No. 1 91Z A 01 n 5—r Owner's Name Add,—ems,and Tel.No. Asses ors ap l� W Installer's Name,Address,and Tel.No. Desi ner's Name,Address,and Tel.No. �3fie) .A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided /�}� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank a--- Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the vironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o He Signed / Date Application Approved by _ Date 'Z�OI4 Application Disapproved by Date 0 for the following reasons Permit No. Date Issued 6i tl 4 t F No. 6 104 Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: e Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Mis p osaf *pstrm Construction Permit —D . 130 v A I` Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Addres//s��or Lot No. 1912 A Q i n 5 l Owner's Name,Address,and Tel.No. Asses tsk&p/Parlly V v, T; 1`m`I-To 3O h n S v tl Installer's Name,Address,and Tel.No. Desi ner's Name,Address,and Tel.No. 313 bxLpvoLfon 56 K- A Type of Building: �p Dwelling No.of Bedrooms �'1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. .M.'r l Description of Soil Nature of Repairs or Alterations(Answer when applicable) &60V 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o e Sign-ed_7 A Date Application Approved by Date C / Application Disapproved by Date . for the following reasons Permit No. -/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance b6YC U t1 L THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed Repaired Upgraded g P Y ( ) P (�) ( ) Abandoned( )by ( (� i at C1 (Z a { n v Q has been constructed in accordance with the provisi ns of Title 5 and the for Disposal System Construction Permit No.— / — dated u t/ t^ �T� � r Installer 7D{� ( ('I 4 Ly-0 y Designer _ #bedrooms Approved design floNy\ Nw gpd The issuance Tthis permit shall not be construed as a guarantee that the system w' 1 ction as designed.Date � � � � Inspector �t-/ �1 S ----------------------------------------------=------------------ .�Q I C, I OfI Fee t No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal Opstem Construction 3permit Permission is hereby granted to Construct( ) Repair(�/� Upgrade( ) Abandon System located at i -2__ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date ��Tj��O(� Approved by - i No. ---^--� Fee-- -- BOARD OF HEALTH TOWN OF BARNSTABLE Applitation- or Well Br5truction permit Application is hereby made for a permit to destruct an Individual Well at: Location — Address Assessors Map and Parcel A ZZ-6 tAl Owner Address Installer — Driller -- Address Type of Building Dwelling — ---- ---- - -- - Other - Type of Building----------------------------- No. of Persons----------------------------------------_-- Type of Well (----�_d( r '�-t Capacity-------- ---- Agreement: The undersigned agrees to dest uct the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board vate Well Protection Regulation. Sign- Application Approved By ' __—_ -----------------____-- --�!__� h date Application Disapproved for the following reasons:-----____________________________________________________—----- --------------------—------- --_-—-_ --- -- - — --- __—-- -- - ------------------------ date Permit No. - D—j> -' O O- Issued--------------� -}J -�- --- —— —— date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well destructed by----------------------------------------------___---___________________—__________ Installer at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has been destructed in accordance with the provisions of the Town of Barnstable Board of Health as described in the application for Well Destruction Permit No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . at. . . . . . . . . . . . . . . . .. . . . . . . :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has been destructed in accordance with the the provisions of the Town of Barnstable Board of Health as described in the application for Well Destruction Permit No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE-------—- --------- --- - --- - _- _ Inspector----------- -----------------—_——-_ —---—--------- ------ Fee—�. BOARD OF HEALTH TOWN OF BARNSTABLE 01pplication Ar Well Zkoructio'n Permit Application is hereby made for a p it to destruct an Individual Well at: - 1A fi r.✓ .S ��r 6 Location — Address Assessors Map and ParcAI Owner Address Installer — Driller -- -- Address Type of Building Dwelling—--------------------- —- - -- —- — Other - Type of Building--------- No. of Pe r�so ns---- TYPe of Well �� «r4 Capacity.......- -----------. — Agreement: The undersigned agrees to destruct the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of-Health`Private Well Protection Regulation. Signed-- - C� `date Application Approved By--�-�-�--------............................ a )) � date Application Disapproved for the following reasons:-- - ------ -- t date Permit No. k?--= 00 O ----- Issued — date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well destructed by--- — Installer at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has been destructed in accordance with the provisions of the Town of Barnstable Board of Health as described in the application for Well Destruction Permit No.. . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . .. . hasbeen destructed in accordance with the the provisions of the Town of Barnstable Board of Health as described in the application for Well Destruction Permit No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . .. . .. . .. . . .. . . .. . DATE-------------------------------------------------—-- -- ---- - Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Uhl[ Degtruction Vermit No.1N (k,__'_00 Fee TS, Permission is hereby granted- -- - to destruct an Individual Well at ' --- Street as shown on the application for a Well Destruction Permit �.� 7� I No.--------------�---------------------__ —_____------------------ Dated---------------------------__----__—_-----__---------- (� Board of Health DATE-------------------J_"x�Q--1 ------------------------------- S/0 Town of Barnstable Barnstable Regulatory Services Department Cftv rp BARNSTABLE, "" Public Health Division m 200 Main Street, Hyannis MA 02601 2007 i Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Certified Mail 4 7008 323000025178 2343 March 14, 2011 1 Amy Johnson 1912 Main Street/Route 6A West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1912 Main Street/Route 6A, West Barnstable, MA was last inspected on 2/18/2011,by Robert Paolini, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s). System will pass inspection if broken pipe(s) are replaced You are ordered to repair or replace the septic system within 2 Years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH mas McKean, R. ., HO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures\229 Saddler Lane,W.Bam.doc. TOWN OF BARNSTABLE LOCATION A%t.sc. SEWAGE# -VILLAGE. ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (sizes NO.OF BEDROOMS OWNER PERMIT DATE: IANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY TOWN OF BARNSTABLE LOCATION j 9/ 1$Z-! (� SEWAGE VILLAGE W• a(�.r�,�-IObI�- ASSESSOR'S MAP PARCEL INSTALLER'S NAME&PHONE NO.�� \�<'�� 2S �C�$-�17? 17 SFPTT( TAT�TTC e Af TTV Q. CLK, 30L,-1 t- T_F A f'L ZW.-FA C T TTV•(4 TC) elam: NO.OF BEDROOMS V OWNER PERMIT DATE: T I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Ad- C✓+0Nrs-4L5 �:� . (n) '� -� � �oQ � � 1CJ � � G � Ca No. gf Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpritation for Bisposal 6pstem Construction permit Application for a Permit to Construct( ) Repair V/) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's J�� Owner's Name ddress,and Tel.No. 31<5-?ef Assessor's Map/Parcel X I(p 05Y tit —54%ilzri. Installer's Name,Address,and Tel.No.,.fG —1171^$g 7 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms _ Lot Size o (J,• sq.ft. Garbage Grinder( ) Other Type of Building C�2S j�Q;act�0.� No.of Persons Showers( ) Cafeteria( ) Other Fixtures A esign Flow(min.required) gpd Design flow provided gpd Pan Date Number of sheets Revision Date Title �• Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. o`� P�� Date Issued REAL ESTATE Sandy Clarke Realtor/Stager/Decorator 70 Packet Drive Dennis,MA 02638 413.531.4458 fax 508.385.6046 sloughsandy@aol.com capecodhometeam.com r �/�j Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plication for Disposal 6pstrin Construction Vertu Appljcation'for a Permit to Construct'( ) Repair(j) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components, A Location Address or Lot No. i9/,;?- Al-414 Owner's Name Address,and Tel.No. 3 fo-gq Q- y//& !/ Assessor'sMap/Parcel ,21(p pay 1 av1�� ork �a�vw*a '6 Installer's Name,Address,and Tel.No.f QE-1/77 8� 11-7 Designer's Name,Address,and Tel.No. l Type of Building: �7 / Dwelling No.of Bedrooms (�- Lot Size o{�S sq.ft. Garbage Grinder( ) Other Type of Building CtitS�i�Q�i"��4�� No.of Persons Showers( ) Cafeteria( ) Other Fixtures esign Flow(min.required) gpd Design flow provided gpd 3 I Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil P ( applicable) TQ a-� 6• -��T C.. Nature of Repairs or Alterations Answer when a licable a.�� -- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ; accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date L- G( f( Application Disapproved by Date for the following reasons Permit No. ad l/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS aJ' BARNSTABLE,MASSACHUSETTS Certificate of ctCompliance THIS IS TO CERTIFY,that the Oh'`site Sewage Disposal system Constructed( ) Repaired V) Upgraded( ) Abandoned( )by C G,pQ ;�Q �w"�er P-_ LA_C at 19 i.Z (fl A yo M5 ��Q- has been constructed in accordance ! - � -( with the provisions of Title 5 and the for Disposal System Construction Permit No. o( — b�` dated Installer�p�Ly .ae- Designer #bedrooms oZ- Approved design flow IL 6— end The issuance of this permit shall not be construed as a guarantee that the system wi'lllf nct on as`-"designed. Date N ` I f_1 Inspector( y ------------ No. 02 D/( - 3 0 fo Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS misposal *pstem �ConstrUttion Permit Permission is hereby granted to Construct( ) Repair(✓ ) Upgrade( ) Abandon( ) System located at /l I P-+ 6A and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructiqn must be com leted within three years of the date of this permit. , �� '� ` Date - Approved by V"`-� v TOWN OF BARNSTABLE LOCATION 121 D/ k�.✓rs y%s�i �v Rf(�(4 'SEWAGE# ?,5�'-�9� VII LAGE T ,/��362 �✓STD a l� ASSESSOR'S MAP&LOT?/�� INSTALLER'S NAME&PHONE NO. I SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 2, cyST /T T (size) NO.OF BEDROOMS r-, B -OR OWNER % a e y THY �_ 0 k PERMITDATE: . / s` 5'S— COMPLIANCE DATE:��.. 4-1��- A4 Separation Distance Between the: Maximum Adjusted Groundwater Table:.nd Bottom of Leaching Facility'`— Feet Private Water Supply Well and Leaching Fa T (I�f }+wr l s�v�us i on site or within 200 feet of leaching faci /g Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le ching facility) r Feet 4 Furnished by D a. 09 O� a D. N ......3 Q............_. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Apphration for Uifipooal Worko Towitrurtion Fumit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: 1912 Old Kings Highway Rte. 6A West Barnstable •------•---...----•---------•-•-•........................•------ ...------•----_.._................ ................... Dorothy Jofd l'` ks same or Lot No. ---•---•--------------........................................................................... -•-............................................................................................... Owner Address W Arch Cons ...... Q - .nn_i ..-•-•---•- =--•Iiyae_------ ••••----•-••-•-.•--•-••-••••••--•-••--....-•-•----•-••--••-•••-••-•--------------------=-------••- ,.a A --- Installer Address UType of Building O 3 Size Lot.'—.......................Sq. feet ►� Dwelling—No, of Bedrooms.._........................................Expansion Attic ( ) Garbage Grinder (/V� aOther—Type of Building ____________________________ No. of persons-__--.:-..__•__-____--_._._. Showers ( ) — Cafeteria (' ) p' Other fixtures ...................................................... W Design Flow......... .1. ............................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank=Liquid capa6ty1000-gallons Length________________ Width................ Diameter......---------- Depth................ x Disposal Trench-- No. .................:.. Width.................... Total Length................._. Total leaching area................... ft. Seepage Pit No....._............... Diameter-------- ._._...... Depth below inlet.._6.............. Total leaching area..................sq: ft. z O,ther Distribution box (X ) Dosing tank ( ) 1 , _ aPercolation�jest-:Results Performed by..................................................-.......................... Date........................................ a Test P•it'.\Toa.1.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ L% Test .Pit \''o: :.:............minutes per inch Depth of Test Pit.................... Depth to ground water........................ . ....._.. Descript�tort ofSoil U .......... .. Y� `--• ••• . ._•• ••••-•.................•-----•--•••.......... . •.-•-- -------------•--•••-•----_-............................................................. 0 Niture:bf Repai-rs or Alterations—Answer when applicable.__'p.1T1.t1a---v_-.upgrade.................................................. --•---......... 9Q:-septic••tanks Phopt.-----a.r>d...6 6...1.�_aCh---Ai_t...�ii.t�h 2 feet...s.t.on2 = Agreement: ;._ ,,'The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ; the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliapce has beeA by t bo of health. Sin .. .......... ........... ....... .. . :... .. ---.-.---.-- .tlA/..95... -- -- ---... —......-' Dare Application Approved By ----- --- ..... .._. .. ........... �--- --------_1------------- --------_.----.-_------ ---------......Date ................ Application Disapproved for the following reasonr: .. .. ....... .................. .............................................................................. '........................ ...: ................ .... .... .... _ Dare .... ?;. Permit No. �,, -� Issued ..... . .. ....V.. ............... .. ... Dat, . 03 ' No Fint3 ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE I ,. , pphratiott for Diripmi tl World, Tonfitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: 1912 Old Kings Highway Rte. oA West Barnstable ••....................•-•----........---•--••-----------•-•-•--------•-.......................... ----•-•-•---------------•-•-•--•-•••............................................................. Dorothy Jotr°(T�`1j-Address same or Lot No. S ......................................\........................_._................_.............. ..._........._.__._............................................................................... Owner , Address ArchConst. Co. y-� H�!ann �......• -•----•----•-------•--•...•••••-•••-•--•----•-•••--•---••-•••-•------••-•-......----•............. x Installer Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms-___-----_-3------------------------------Expansion Attic ( ) Garbage Grinder (W) Other—Type T e of Building ............................ No. of ersons___-______-____. --_.---- Showers — a YP g P ---- � ( ) Cafeteria ( ) Other fixtures ------------------------------------------------------ -_.-/ W Design Flow........1 .O gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity1000-gallons Length.-.............. Width................ Diameter................ Depth................ Disposal Trench--No. .................... Width.................... .rotal Length.................... Total leaching area....................sq. ft. Seepage Pit No------- ............. Diameter........ .......... Depth below inlet.._6...__......... Total leaching area..................sq. ft. Z Other Distribution box (X ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth 'of Test Pit.................... Depth to ground water........._.............. (ter Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•------------- .......................................................................................................................................... Descriptionof Soil....:.........•--•---------------------------------------------......--••--------------------------------------------....---......---................---....---.....:-•- W V .................................................:...................................................................................................................................................... W .---•----------------------------------------------------------------------------------------------------------------------------------------------•-----------------------------------..............•. U Nature of Repairs or Alterations—Answer when applicable...T1TLE-__V-_--upgr.a.d_e.................................................. .............. 000...s tic••-tank-•-Dbox-•-•--and--6x6...leach_---p1_ 2... e stoma .................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued-by t e bo 4lof health. Signed� �...: .............� ............ ............ ------------. ............3./.-1..4../...9: ... /I a� Dare Application Approved B ...................'..r...11, i..�......... ....:- ... ' Mte Application Disapproved for the following reasons: / ................ ..... ............................. . -- ..................... ................... ............................................... ..... ... ....^..:..-..... .. . ... ........................................... ............... ;................ . �.�....... �f Date Permit No. !!! _ .. ............... Issued ..... :. v,e .... .................... ---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tier#tftra a of (gontlatittnce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by.............ARCH CONST. CO _......_... ..... ........ .............................. .................................. ... ` Inswk, at ---.................................................OLD----K-INGS..-H_I.GHWAY__WE.ST....13ARhIS-TABLE....-.-. has been installed in accordance with the provisions of TITLE 5 o he race Envy nmental Code as described in the application for Disposal Works Construction Permit No. -..-...v!. s....9--.dated ..--:- HALL NOT BE C�NSTRVEI7 �►S A GUARANTEE THAT THE THE ISSUANCE OF THIS CERTIFICATES SYSTEM WILL FUNCTION SATISFACTORY DATE ..._ /✓ ..-....�� ..... ...... Inspector _._ --------------��...��f�..�'1�� --.----------------------------------------------- ---•-----. .e ---- ----- THE COMMONWEALTH OF MASSACHUSETTS f BOARD OF HEALTH TOWN OF BARNSTABLENA,!) �- FEE..... ........... Disposal Works Tot;otrudion "rrmit Permission is hereby granted........... ---- RCH CONST. CO. ------------- - to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at No.. 19-1 O TtI?__- z�r�! S TA�1T_ .... -------------------r ----�......-�...... Street J ..-� as shown on the application for Disposal Works/ConstructionT Permit No... __ 1)atted....�.. _.� IL...![n+�:_....... W� Board of H alth DATE -------------••••---••--• 3-�... \\ r --------------•-----•- FORM 36508 HOBBS A WARREN,INC..PUBLISHERS 3 � t