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Home My WebLink About1970 MAIN ST./RTE 6A(W.BARN.) - Health 1970 Main Street/Rte 6A (W.Barn) W. Barnstable A = 217 014 r�. L. 4a- 2,2 2-coy - l a 2 yo�ucr.Y �fn G jr, Ch Z .�,OOCx.psL ,pyppgx�p•,y L� 1. s � .Os00Cx.�Z aQ"i9 ag iot 71 vJ-iei 4 56'-0" 13'-4" 12'-3„ 10'_2" 8'40" sa:+a saxra• ` raxra sa'xsa rcYxa � - ♦ ,• _ ti5'� o; 5- co b -� § ~ y Zo 11� Bedroom b I o N #3 "' Bedroom 2'3„ I Laundry #2 4 � " Family Room a re•,a---- 10'-2" 10'-$" �J 7.g•Yea - § �O N On I aie- axe • YeaeF xeaeF 51-0.1— 12'-0" aa_:eaco--- -------------- ----- --- - — 6•4 cvxea'cro CV �D n eax e• e•ax s• � r• n k -8 5" _5,6 Breakfast _ a Nook Living/ � Bedroom b Dining Room N Kitchen #1 § O C.0 dl p O sa x ea "5- " 5'-9" 13'-10" 3'-10' 15W" . 41'-1" Cb 1970 Main St CO Porch 'n Floor Layout ' 25'-i0" Commonwealth of Massachusetts Title, 5 Offici_a! Inspection Form Subsurface Sewage Disposa{System, Farm, Not for Voturitary Assessrnertts a e' 1970 Route 6A e MM .J I Property Address r+ . Towne Owner Owner's Name information is : required for every West Barnstable MA 02668 April 2, 2018 t page_ City/Town State Zip Code Date of Inspection pM, 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. >finng out form,s, A. elra;elra riforilna ion filling out fauns b on the.cornputet,. use only the tab 1. Inspector: key to move your cursor-do not Edwin C. Gibbs Jr. use the return Name ofanspecto.r. key: Gibbs Septic Service Company Name 2 Oriole.Lane -Company.Address Sandwich MA 02563 City/Town State Zip Code (508) 888-5871 1750 Telephone Nwmber bioense Number B. Certification I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time 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 DE'P approved system inspector prtrsuattt•to Section.15:340.:of Title 5(310,CMR TS.000y: The systertii Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heaith or:`DEP).Wit hin"30 plays-6f comotdting this<in-specfiom.1.Rbe sWeem,-iis a 4h.ared 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 DER 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 �-°0 V's f Commonwealth of Massachusetts y Title. 5-.Official Inspection- Form Subsurface-Sewage:Disposal System Far t-Not,for Voluntary Assessments ^M 1970 Route 6A Property Address Towne Owner Owner's Name information is West Barnstable MA 02668 Aril 2 2018 required for every p page. City/Town State Zip Code Date of Inspection B, Cerllfiiction (cont.) r Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: CK I have not found any information which,indicates that any of the failure criteria described iTT 31.0 CMR 15.303 or in-310 CMR 15,304 exist: Any failure criteria not.evaluatec[are . indicated below. Comments: "B3 -Sy tem Qo',diticanally"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"hot determined'"(Y, N, ND)for ttte foRowi.ag..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 ansound;.exhibits substant al Infiltration or exfllteation or tankfailure is imminent:System-willr.pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A.metal-septie1an.k 1.1-,pass-inspectio..nifit-is�structurally,:sound,::notieakingand:lf,-aCertificate:af 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 SysteR Form.- Not for Vol,,Untary.Assessments - ;M 1970 Route 6A Property Address Towne Owner Owner's Name information is West Barnstable MA 02668 Aril 2, 2018 required for every p page. City/Town Mate Zip.Code Date of Inspection .`°Certi#icatio°n°(corn) ❑ 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 1lealth): ❑ 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): El_ 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 Heatth 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 El Cesspool or-privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•31.13 Title-5 Official Inspection Form:-Subsurface Sewage Disposal'System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official .Inspeetio For Subsurface Sewage Dlsposai System Form,-Not for Voluntary Assessments M 1970 Route 6A Pro perty Address Towne Owner Owner's Name information is West Barnstable MA 02668 Aril 2 2018 required for every p , page. C.itylTown State Zip code Date of Inspection B. Certif affi n (cost.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) sJetermines'thatthe_systemTMis"`f r�cti rieng rn amarr rthat,p tests t e ltalic;lae , safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of ar surface water supply,or tributary to,ar surface water supply. ❑` The..system.-has a-septic tank:and-SAS and the-SAS is with h-a-Zohe_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 100r.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 ess than 5.ppm,-provided that no other failure criteria are triggered. A copy of the analysis must be'attached'to#his'form. 3. Other: D) System Failure t;tatelna Applicable b All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ rX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or pondir g;of'effloeht to the surface of the groin- di 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 betbw invert'or.available vokime is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Fort. Subsurface Sewage D7sposaf Sys'terrr Form-Kfot-far Valuntary Assessments-` M 1970 Route 6A Property Address Towne. Owner Owner's Name information is West Barnstable MA 02668 Aril 2, 2018 required for every p 1page. City/Town State Zip Code Date of Inspection $. Cerfifica on (conv) Yes No -Regt*ed:purnping.:rnore-than 4.t es'sn_the%last year MOT doe to clogged or obstructed pipe(s). Number of times pumped: ❑ [;K Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion-of cesspool'or privy:is within:,TOO 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. ❑' CK Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ A.ny,,portion of a cesspool or.privy is Jess than 100-feet but greater than 50 feet from a;private.water sgpoy well with no acceptable water quality analysis..jTh1s 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, prn Vtd,-i&d.that no-other failure:c:rtte.tiarare triggered. IAe,copy oftheanaly6is and chain of custody mustbe attached to this form] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- - 1 tk,.I�OQgpd`r. The system fails. f 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 foiiowing,.-in..additmn 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. El 0 Area— IWPA) or a mapped Zone 11 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-abovethe rangesysterm,has,faid'ed Thie-:owrner=.or operafor.of any largo system considered a significant threat under Section E or failed"under Section D shalf upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. thins•3/1'3 Title 5 Official Inspection Form'Subsurface Sewage'Disposal System;Page'5 of 17 i Commonwealth of Massachusetts Title 5 Official Ins eetior- Forte- Subsurface Sewage Disposaf Systerrr Form- Not for Voluntary Assessments 1970 Route 6A Property Address Towne:. Owner Owner's Name information is West Barnstable MA 02668 Aril 2 2018 required for every p page. Oity/Town State Zip Code Date of.lnspection C. Cheokiist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ K Pumping information was provided by the owner, occupant, or Board of Health El [, Were any.of the system components pumped out in the previous two weeks? ❑ 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? 9 ❑ Were as built plans of the system obtained and examined? (If they were not ava`ilable;rote 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 fao the condition of the baffles or tees: material-of.construction; dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Ig Was the facility owner(and occupants if different from owner) provided with infornaation<on,the proper maiRrtenanee of suibsurface,sewage dis.posal,systems? The size and location of the Soft`Absorpti`on Systern(SAS)on-the site has been determined based on: Exisbn,g information. For exam-ple,.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): Number of bedrooms (actual): 5/yo DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts F Titte 5 official Inspection Form. s Subsurface,Sewage bisposai System-Form-- h ot.far Vofuntary Assessments 1970 Route 6A property.Address Towne: Owner Owner's Name information is West Barnstable MA 02668 Aril 2, 2018 required for every p ipage. C.dy/Town State Zip Code Date of Inspection D. System-lnfiormation Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No Fymform�ationaim-thisvepor . Laundry system inspected? ❑ Yes JSa -No Seasonal use? ❑ Yes ® No G c Water meter readings,if available 1ast2 ears usage d 6 0 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes EX, No Last date of occupancy: Dahe Commercial/Industrial Flow Condition's-: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/scl it., 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-3113 Title 5 Official Inspection Form:Sdbsurtace Sewage Disposal System-Page Tof 17 Commonwealth of Massachusetts Tithe - official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 1970 Route 6A Property Address Towrte: Owner Owner's Name information is West Barnstable MA 02668 Aril 2, 2018 required for every p ,;page. City/Town State Zip Code Date ofImpection D. System Information -(cont.) Last date of occupancy/use: 'el-� a01(a Date -other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? [ Yes ❑ No 6/1 If yes, volume pumped: /0 ©o gallons I 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 techinologp.Attach at copy of the curtre-ni cpemfion 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 ii ❑ Tight.tank.Attach a copy of the DEP approval. ❑ Other(describe): f y.� k t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts F 't :e 5 Official insp�lctiv�n Form, Subsurface Sewage tii$pos#System Form - Not for Voluntary Assessments 1970 Route 6A P�opelAy Address Towne Owner Owner's Name information is West Barnstable MA 02668 Aril 2, 2018 required for every p page. C,itylTown State Zip Code Date of Inspection 'D. Sys#emlnformafion (coat.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes [X No Building,Sewer(locate on site plan):. Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: -feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 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: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Qis:posal:System or Not for bolur*tary,4ssessments 1970 Route 6A Property Address Towne Owner Owner's Name information is West Barnstable MA 02668 April 2, 2018 required for every P i page. CityfTown State Zip Code Hate of.Inspection <D.�Syste�n J ii orlmaftn. (cone:) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from tap of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? � Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid:levels..as r-elateed t:outlet invert;..evidence,of leakage,=.etc:). f. IV 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 E €iota Irsetian Form Subsurface,Sewage Disposal System Form, Not for Voluntary,Assessments . °M 1970 Route 6A Property Address Towne Owner Owner's Name information is West Barnstable MA 02668 April 2, 2018 required for every p 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, -1iq)jad,aevels as xe;lated to outlet invert,.evidence of leakage, etc.): Vg:Ett or..,Ho1dI`ng Tank(tank must be purrrped"at tine of inspectl:ort) (focate ors site plarr): Depth below grade: Material of construction: ❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gdttons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of.1ast,pumpin,g- 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 w Title 5 official Inspection Form. Subsurface Sewage Disposai'System EorM- Not for Vol:u.rntary Assessments wM 1970 Route 6A Property Address Towne Owner Owner's Name information is West Barnstable MA 02668 Aril 2 2018 required for every p Page. City/Town State _-Zip..Code Date.of.Inspeotion D. Sy l m Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into-or out of box,.etc..): 12 Pump Chamber(loca'te on site plan): Pumps in working order: E_ Yes 0 No* Alarms in working order: 0 Yes 0 No*- Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,,explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official InspeLLc1tion :Form Subsurface Sewage,Disposal System Form- Not for Volun..tary Assessmemrts ,M 1970 Route 6A Property Address Touvne ' Owner Owner's Name information is West Barnstable MA 02668 Aril 2, 2018 required for every p page. City/Town State Zip Code Date of.lnspection D. System .lnformafioh (cont.) Type: leaching pits number: leaching chambers number: leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,-81gns of'hydraufic failure, level 6'fponding, damp soil,condition of vegetation, etc.): Cesspools (cesspooV must'be p:umped.as part of=inspection) (locate on site plan): Number and configuration Depth -top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Dis.posaf System Form Not for VoV:untary Assessments °M 1970 Route 6A Property Address. Towne Owner Owner's Name information is West Barnstable MA 02668 Aril 2, 2018 required for every p .page. 0ty/Town State Zip Code Date of Inspection -0: system 10forma'tion:(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, Privy(rocate 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.): i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form. SUbsurf ice Sewage DispoWSysteft Fo.firri Not for.'Voturitary Assessrnerits. ;M 1970 Route 6A PKoperty Address. Towne Owner Owner's Name information is West Barnstable MA 02668 Aril 2 2018 required for every p page. CitylTown State Zip Code Date of Inspection D. System if-if ormat on:(cost:) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to atleast two perMa erax Deference landmarks os,benchrxaarks. Locate all weals 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 ob �o. L /13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DFsposaR'System Form-N.ot'for Voluntary:Assessments 4M 1970 Route 6A Property Address Towne= Owner Owner's Name information is West Barnstable MA 02668 Aril 2, 2018 required for every p page. CitylTown State Zip Code Date of Inspection D. system 1'hfor mation (cone.) Site Exam: R Check Slope ❑ Surface water Check cellar ® Shallow wells , Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: El Obtained-from-system design-plans on record If checked, date of design plan reviewed: ®ate ❑ 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. 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 M0 1970 Route 6A Property Address Towae: Owner Owner's Name information is West Barnstable MA 02668 Aril 2, 2018 required for every p .page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked f Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information— Estimated depth to high groundwater Sketch asewage Disposal'System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °p 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W.Barnstable MA 02668 6/7/13 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 on the q.1 computer,use 1. Inspector: only the tab key to move your Jason P Burnie cursor-do not Name of Inspector use the return key. Neighborhood Waste Water Company Name 350 Main St Company Address Yarmouth MA 02673 �II171 Cityrrown State Zip Code 508-775-2820 S15011 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/7/13 Inspector's Signal- / 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 Inspectio orm: bsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W Barnstable MA 02668 6/7/13 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® i have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was found in good working order at the time of inspection. The septic tank inlet cover is 5"deep. The outlet is 1' deep. The d-box cover is 17". The SAS cover is 74"deep. 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 Formes Not for Voluntary Assessments 1970 Main St Property Address _Jon Ferguson Owner Owner's Name information is required for W Bamstable MA 02668 617/13 every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W Barnstable MA 02668 6/7/13 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 El ® 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 %day flow 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W Barnstable MA 02668 6/7/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. , ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y� 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W Barnstable MA 02668 6/7/13 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): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): SAS@ 463gpd t5ins•3/13 Title 5 Official Impeclion Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts IJ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W Barnstable MA 02668 6/7113 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System consists of a tank, d-box and 3-500gallon drywells Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 12=214gpd g ( y g (gp )) 11= 167gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Current 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1970 Main St Property Address Jon Ferguson Owner Owners Name information is required for W Bamstable MA 02668 6/7/13 every page. Cityrrown 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: 2011 per info at the Barnstable BOH Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W Barnstable MA 02668 6/7/13 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: 2004 per plan on file at the Barnstable BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'1" Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): We ran a sewer camera up the main line and it was ok at the time of inspection. Septic Tank(locate on site plan): Depth below grade: Inlet-5" Outlet- 1' 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: 1500gal Sludge depth: 10" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is W Barnstable MA 02668 6/7/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2 Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 4"+ - Distance from bottom of scum to bottom of outlet tee or baffle 1'+ How were dimensions determined? tapemeasure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was found to have both T's in place and it was at a normal level at the time of inspection. 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 o-utlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W Barnstable MA 02668 6/7/13 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-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 1970 Main St Property Address Jon Ferguson Owner Owner's Flame information is W Barnstable MA 02668 617/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was found in good condition at the time of inspection. It was at a normal level. The cover is 17'deep from grade. 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: SAS was located. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W.Barnstable MA 02668 6/7/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-500gal drywells w/stone ❑ 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.): The SAS was found to have 2"of standing water in them at the time of inspection. The deck and cover for the SAS is 2'4"deep. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W Barnstable MA 02668 6/7/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W.Barnstable MA 02668 6/7/13 every 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 t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewwwwage Disposal System Form-Not for Voluntary Assessments qO a i (\ 6 f (RT, (o A ....... Property Address Owner Owner's Name information is �,l �r Ins�-a l e required for every — page. Cttylrown State Zip Code Date bf 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 1 w L 3 Z CA zv s� z - 4q 3 Sty t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pepe 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W.Bamstable MA 02668 6/7/13 every page. CityfTown 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: 20' per plan dated 2004 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: 2004 on file at the Barnstable BOH 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: SDW-252 Zone A water level 46.5 .6x12=6"adjustment You must describe how you established the high ground water elevation: On plan dated 2004 test hole 4 was done where the SAS was installed and it showed no water for 20'. From grade to bottom of SAS it is 62". This gives you a proven seperation of at least 14' between the bottom of SAS and where groundwater is known,not to be. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1970 Main St Property Address Jon Ferguson Owner Owner's Name information is required for W.Barnstable MA 02668 6/7/13 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 � y , COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1970 MAIN ST W-BARN Q Owners Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection:6/9/06 Name of Inspector: (please print) Douglas A.Brown ' Company Name: Douglas A.Brown Septic Inspections Mailing Address:P.O Box 145 "} c Centerville,MA 02632 Telephone Number: 508-420-4534 t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 6/9/06 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. Notes and Comments ""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. Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000 4 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1970 MAIN ST W-BARN Owner's Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection: 6/9/06 inspection Summary: Check A,B C D or E/ALWAYS complete all of Section rY pD A. System Passes: X I have not found any information winch indicates that any of the failure criteria described in 3 10 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 Pase' 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. Answer yes,no or not determined(Y,N,ND)in 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1970 MAIN ST W-BARN Owner's Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection: 6/9/06 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 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 I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1970 MAIN ST W-BARN Owner's Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection:6/9/06 D. System Failure Criteria applicable to all systems: You must indicate"yes or no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 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. You must indicate either"yes" or no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 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 y8s'm 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 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1970 MAIN ST W-BARN Owner: CRESCENT PROPERTIES Date of Inspection: 6/9/06 Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No X Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks ? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? Were all system components,excluding,the SAS,located on site? X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3 ))(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1970 MAIN ST W-BARN Owner's Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection. 6/9/06 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NA Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NA Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): NO Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 2001 GEORGE BOTELHO Were sewage odors detected when arriving at the site(yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1970 MAIN ST W-BARN Owner's Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection: 6/9/06 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ (locate on site plan) Depth below grade: 12" Material of construction: X concrete_metal_fiberglass _polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 1500 gal Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle: 0 Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: 0 Distance from bottom of scum to bottom of outlet tee or baffle: 0 How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- HOUSE BASICALLY HAS BEEN EMPTY SINCE SYSTEM INSTALLED GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass—polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1970 MAIN ST W-BARN Owner's Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection: 6/9/06 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): X L9,e PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1970 MAIN ST W-BARN Owner's Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection: 6/9/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: X leaching chambers,number: 3 ' t3'2`� X 3-5'G Pi 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.): PITS ARE DRY AT THIS TIME CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,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.): I Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1970 MAIN ST W-BARN Owner's Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection: 6/9/06 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. ,312.01 2��G © a 3 Page l I of I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1970 MAIN ST W-BARN Owner's Name: CRESCENT PROPERTIES Owner's Address: Date of Inspection: 6/9/06 SITE EXAM Slope: Surface water: Check cellar: Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: TOWN OF BARNSTABLE C• C LOCATION /9-7-® ,nA ARC•(_, e �. pia _ SEWAGE # 2 OC VILLAGE 1A) Laf� s� 1 f ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY lS--E20 6fa LEACHING FACILITY: (type) ." (size) ��3•(o X I 1 NO.OF BEDROOMS BUILDER OR OWNER COp4 �R��GZ S�P� C�r�`� �n • a i/`tL. PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 3' 5 CP a 3�' NO. THE COMMONWEALTH OF MASSACHMSETTS .� FEE BOARY OF HEALTH lin M OF b APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade ('1, ) Abandon ( ) - ❑Complete System ❑Individual Components � &YoT co I l Locat'on Owner's Name Q0 .0/ Map/Parcel# Address # 141 /1 Installer's e ( Designer's me , 02 L/9.ee/14 /`©i� •�str lovTl/ d 7 2 Telephone# Telephone# . Type of Building: Lot Size 7J�/ Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. equired) gpd Calculated design flow gpd Design flow provided� 6� gpd Plan: I ate Z- -0 Number of sheets _ Revision Date Title. Description of Soil(s) L. h o lc/J Soil Evaluator Form No. Na of Soil Evaluator ,.Gc�tr Date of Evaluation] of DESCRIPTION OF REPAIRS OR ALTERATIONS P The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspec t FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 li'.- )A09It No. _ THE COMMONWEALTH OF MASSAC SETT'SF � FEE W BOAR OF HEALTH If Tn 01 APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair (' ) Upgrade (\/) Aod ( ) - ❑Complete System ❑Individual Component's Jq D Pe GPI 'Ot Utz..64s & (_&or. 61, h4c s Location � Owner's Name i Q>�7 2j Map/Parcel# Address a.10 -- Lot# Tele hone# �o�.eGE c�r.�r.yo �+ /A• Installer's Designer's me .l. !,Z Address s 2. Telephone# Telephone# I Type of Building: -�- F 7.7 v S feet yp g Lot Size q. Dwelling—No.of Bedrooms ► Garbage Grinder Other—Type of Building x No.of persons Showers ( ), Cafeteria_14 ( ) Other fixtures "� j � 1 Design Flow(min. quire/d) =7 gpd Calculated design flow gpd Design flow provided,43 gpd Plan: ate 2` D'-1 Number of sheets Revision Date 1 Title, _ / p f, \ ' Description of Soil(s) OA,(-aj6'P _., 4r at-k C_ Ai4llTa 1 A&&4A, I ° l Soil Evaluator Form No. Na4jOf Soil Evaluator r. A� Date,4 valuation/1-20-63 DESCRIPTION OF REPAIRS OR ALTERATIONS Y The undersigned agrees to install the above described Individual Sewage Disposal System in yaccordance with the provisions of TITLE 5 and further agrees of to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ..a/ Date r Inspeclo } fI, FORM 1 - APPLICATION FOR DSCP DEP�APPROVED FORM'5/96 � I No. f© T E COMMONWEALTH OF MASSACHUSETTS f FEE (id f r - r rrS' A' BOARD OF HEALTH I CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) MComplete System. The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: Y_to/ 10 tat• Sq r has been installed"in accordance with the provisions of 31 C R 5.00 (Title 5) and the approved design��jtans/as-built �.. plans relating to applicatio No.�z1-1U�dated —' Approved Design Flow 7 �{� (gpd) lh�Installer Designer: Inspec Date The issuance of this certificate shall.not be construed as d.guarantee that the system will function as designed. i FORM 3 - CERTIFICATE OF COMPLIANCE ,- DEP APPROVED FORM 5/96 t i No. Id�THE COMMONWEALTH OF MASSACHUSETTS Q FEE v BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrad,Rh'A�bandop ( ) an individual sewage disposal system at �'70 fin#%IN ��"' �' b 1 r��:�`Q,b �� as described in the application for Disposal System Construction Permit No. QM14 — 10'4— dated 3 45 16 Ll Provided: Construction shall be completed within three years of the date of is perrt�i loc conditions must be meta Date S Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 r FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS - BOSTON III ;I 'down-of Barnstable Regulatory. Services .. �` } Thomas F. Seiler,-Director • aAarr9rnatE; • Public Health Division. 1639. Thomas McKean,Director' 200•Main'Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 f Installer& Designer Certification Form Date: Sewage Permit# /O)Assessor's'TN1ap\Parcel Cx Designer: Installer: Address: r 1 -! icy: �I <<.i i t i C_ Address:. 1��• ��.�( �49T u On was issued a permit to install a (date) (installer) septic system at I j_IL• \ /lC/1 y -7)C-t ;�,-) based on a.design drawn by (address) r ��.��" dated ,� ;; (de 'gner) I':certify that the..septic system referenced.above was installed substantially according to the design, which may- include minor approved changes'such-as lateral relocation of,the distribution box and/or septic.tank.. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but'in.accordance with!State & Local Regulations. Plan revision or certified as-built.by designer to follow. stalle s ture) �S� DAVivCHAR �= SAi�iCK! (Designer's Signature) 1 1 Desoi�nq Here). . F UST ,l PLEASE RETURN TO BARNSTABLE PUBLIC HE L " CERTIFICATE OF COMPLIANCE:WILL NOT BE ISSUED UNTfL-- BOTH THIS'YM AND AS-BUM.T..LARD .ARE:.. _ RECEI "Y-THE BARNSTABLE PUBLIC BffiAkTH D"10N.. TRANKYOU. C)-Haaith/.Rentirlrlezionvr('Pr}ifir.ntinn Form: LIA U rinr TOWN OF B.ARNSTABLE C, LOCATION l�r v�.�A�.LI ..S I �A� SEWAGE # 2 00`'{ r®;3 i VILLAGE Iv. 1 �`r'� I ASSESSOR'S MAP & LOT d 1 INSTALLER'S NAME&PHONE NO._ kv k&`ri f � 8-9 SEPTIC TANK CAPACITY � � <L�.1 GAI LEACHING FACILITY: (type) > NO.OF BEDROOMS BUILDER OR OWNER Ckpi PERMITDATE: 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 ��l �S COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 20 RIVERSIDE DRIVE, LAKEVILLE, MA 02347 508-946-2700 ARGEO PAUL CELLUCCI BOB DURAND Governor Secretary JANE SWIFT 'W LAUREN A.LISS Lieutenant Governor CCIT j Commissioner September 28,2000 Douglas Delprete RE: BARNSTABLE-BWSC Delprete Corporation RTN: 4-14788 760 Summer Street Route 6A&Route 132 Rockland,Massachusetts 02370 Stonewall Lane NON-SE-3T-141 NOTICE OF NONCOMPLIANCE THIS IS AN IMPORTANT NOTICE. FAILURE TO TAKE ADEQUATE ACTION IN RESPONSE TO THIS NOTICE COULD RESULT IN SERIOUS LEGAL CONSEQUENCES. Dear Mr.Delprete: The Massachusetts Department of Environmental Protection, Bureau of Waste Site Cleanup (the "Department"), is tasked with ensuring the permanent cleanup of oil and hazardous material releases pursuant to Massachusetts General Law Chapter 21E ("Chapter 21E"). The law is implemented through regulations known as the Massachusetts Contingency Plan,310 CMR 40.0000 et seq. (the"MCP"). Through the MCP, the Department is currently regulating a release of oil that occurred at Stonewall Lane in Barnstable, Massachusetts. The Department was first notified of the release on June 11, 1999. The.Department's records indicate that you (as used in this Notice, "you" collectively refers to Delprete Corporation)are a Potentially Responsible Party("PRP")for this release. This Notice is provided to inform you that you are not in compliance with the MCP. The Department has no record of your completing the response actions required by the MCP to address this release.. Attachment A of this Notice is a Noncompliance Summary sheet that outlines the provisions of the MCP that you have not complied with. Contained within the Noncompliance Summary are the necessary action(§) you must complete to return to compliance. Additionally, there is a prescribed deadline for your completion of the action(s). This information is available in alternate format by calling our ADA Coordinator at(617)574-6872. DEP on the World Wide Web: http://www.state.ma.us/dep �� Printed on Recycled Paper Page 2 The Department may assess a Civil Administrative Penalty potentially in excess of$7,000 if you continue to be in noncompliance with the violation(s)cited herein. Notwithstanding this Notice of Noncompliance ("NON"), the Department reserves the right to exercise the full extent of its legal authority in order to obtain full compliance with all applicable requirements, including, but not limited.to, criminal prosecution, civil action including court-imposed civil penalties, or administrative penalties assessed by the Department. Finally,Attachment 2 of this Notice is a fact sheet containing supplemental information regarding this NON. If you have any questions regarding this matter, or if you would like to discuss compliance with this Notice,please contact John Handrahan,at the letterhead address or by telephone at 508-946-2883. All future communications regarding this matter must reference Release Tracking Number 4-14788. Very truly yours, nathan E.Hobill,Regional Engineer ureau of Waste Site Cleanup H/JH/ka Attachments: Attachment 1:Noncompliance Summary Sheet Attachment 2: Supplemental Information.Regarding This Notice of Noncompliance Certified Mail#Z 240 878 379 Return Receipt Requested cc: Barnstable Board of Selectmen Town Hall 367 Main Street Hyannis,Massachusetts 02601 Barnstable Board of Health Post Office Box 534 Hyannis,Massachusetts 02601 DEP-SERO Attn: Regional Enforcement Office(2 Copies) Data Entry . f ATTACHMENT 1 NOTICE OF NONCOMPLIANCE NONCOMPLIANCE SUMMARY ENTITY/POTENTIALLY RESPONSIBLE PARTY IN NONCOMPLIANCE: Del prete Corporation 760 Summer Street Rockland,Massachusetts 02370 LOCATION WHERE NONCOMPLIANCE OCCURRED OR WAS OBSERVED: 4-14788 Route 6A&Route 132 Stonewall Lane Barnstable DATE(S)WHEN NONCOMPLIANCE OCCURRED OR WAS OBSERVED: June 11,2000 August 11, 1999 DESCRIPTION OF ACTIVITY OR CONDITION RESULTING IN NONCOMPLIANCE: 1. You have not submitted a Response Action Outcome (RAO) Statement, Tier Classification Submittal or Downgradient Property Status Submittal to the Department. One of the above referenced documents is required to be submitted to the Department within 1 year of notification that a,release of oil and/or hazardous material has occurred, as is required by 310 CMR 40.050.1(3). 2. You have failed to submit a Release Notification Form (RNF) to the Department as required by 310 CMR 40.0333 and 40.0336. DESCRIPTION OF REQUIREMENT NOT COMPLIED WITH 1. Pursuant to 310 CMR 40.0501(3), except where a site has filed a Response Action Outcome (RAO) or a Downgradient Property Status Submittal, all sites for which the Department receives notification of a release or threat of release of oil and/or hazardous material pursuant to 310 CMR 40.0300 on or after October 1, 1993, shall be classified as either a Tier I or Tier H disposal site in accordance with 310 CMR 40.0500. A Tier Classification submittal and, if applicable, a Tier I Permit application, shall be submitted to the Department within one year of the earliest date computed in accordance with 310 CMR 40.0404(3). 2. Pursuant to 310 CMR 40.0333 and 40.0336, persons described in 310 CMR 40.0331(1) shall submit to the Department a completed Release Notification Form within the earliest of the following dates: a) . within sixty(60)days of your notifying the Department of the release condition, or, b) within sixty (60) days of your receipt of a Notice of Responsibility (NOR) from the Department. DESCRIPTION AND DEADLINES OF ACTIONS TO BE TAKEN To avoid imposition of a Civil Administrative Penalty in the amount of $7,000 for violations of the MCP,you must complete the following action(s)within thirty(30)days of your receipt of this NON: 1. Submit to the.Department either a Response Action Outcome Statement, Downgradient Property Status Statement,or a Tier Classification. 2. Submit to the Department a completed Release Notifification Form., All items must be prepared in full accordance with the MCP. Notwithstanding this NON, the Department reserves the right to exercise the full extent of its legal authority to obtain full compliance with all applicable requirements, including but not limited to, criminal prosecution, civil action including court-imposed civil penalties, and Civil Administrative Penalties issued by the Department. 1st FLR. SYSTEM PROFILE Y 0 S S MAIN HOUSE NOT TO SCALE ELEV.82.0 FINISH GRADE FINISH GRADE 8 a o o FINISH GRADE OVER EL. OVER TRENCHES 72, o SEPTIC TANK 7-6- - ' �-RISERS TO 6tt •,_, :,A PRECAST CONCRETE OF FINISH GRAD ,o ! FINISH GRADE OVER H-10 REINFORCED LOADING •'%,'' :,''o;b'.r''- 1^ ,°,,:.;,,, .p DISTRIBUTION BOX 77, 0 3"MAN. TRENCH LENGTH = 33'-6" 01 MIN.SLOPE 1% :o DRYWELL LENGTH = 8'-6" 13" 6" MIN.SLOPE 1% MIN ~` Oj0 t �,:r fir. .,t �;O:f rr 0.� i " 14" n -J =f_ �•� ::�a 13 MIN. RISERS TO 6 �''o` 'o•o ,a .b'o. b'pio, o' '" r 1�\ Tom/' 7o MI OF FINISH GRADE t' OUTLET PIPE(S) LEVEL �, PVC OR CAST IRON TEE -�y 7yZs o FOR 2'( MIN.1% SLOPE Z ; ` o'9 2 O L 6 BEYOND) 3/4"- 1-1/2" DOUBLE - � _ O 3/4"- 1-1/2" DOUBLE t a , ;, t WASHED CRUSHED 4 ,o . , ,_ • 6"SUMP '•' STONE WASHED CRUSHED 0 1500 GALLON W = p STONE a ` 72,Sb PRECAST CONCRETE BSMT.FLR. o. a H-10 REINFORCED a DISTRIBUTION BOX ELEV. \� _ TRENCH SECTION S>•-��-• - 1. :•• MINIMUM INSIDE DIMENSION 12" OUTLET INVERTS 2" BELOW INLET INVERT NOTE: EXCAVATE TO =C= STRATUM IN ORDER TO MINIMUM CONCRETE WALL THICKNESS 2 r °• r. Or e�rrr r 'Q ♦- '� rrf ,\-Ip 0� " '' `r' n `r n n n n _ '0 ,• . ,, , o , . , or.•_• r REIWIOVE ALL =A= & =B= IMPERVIOU�`MATERIAL INSTALL ON COMPACTED LEVEL BASE WITHIN 5' OF THE SAS. REPLACE WITH CLEAN, 9 MIN. 3 OF 1/8 - 1/2 SEPTIC TANK CLAY-FREE SAND 4 DIAM. 36" MAX. DOUBLE WASHED INSTALL ON COMPACTED LEVEL BASE PEASTONE 310 CMR 15.255 -L 1 •'0 _�• •:, o,p. it •„,ot' ., r..- i ,.pa„ ,-�� ; `�°' •. •r .r D'o. 3/4 - 1-1/2 DOl°1BLE ° °T 4 tr I 5-2 WASHED CRUSHED - - - -. I STONE TRENCH WIDTH f y I , wry • 1.:r$.�0 •-._, r�: ','* d r '/� S t t r, .. - .._a".Sj•i .0•x _ r n _ �y - _ "UMBER OF TRENCHES 1 - Lw..a. MBER OF DR ELLS 3 I i -Y r � 0 1 \ R t• a r .'k V f' I•` ,, n t,, �ai y B43 2Z $� a 0 `. / / V v. / ,+ �'�.@l4•^r _ U. ��...- �A ' 'lads l - 1 78.9 \ � \ t n i.•,...e:*., .r-a•n.rw non- I N r p _ 80.9 ti OBSERVATION PIT 8 / 0 77.6' I P-10,628 PERCOLATION RATE: < 5 MINAN t� /+ + ` WITNESSED BY: D.STANTON 78.7 8.1' � ( BARNS.'BOARD OF HEALTH f / DATE: DEC.29 2003 & FEB.S 2001 + , ! 3 � 78.2 a r + r f „ f 79.4 o ` z + + ♦ /` GENERAL NOTES: r" 7-,y z .� T� -� DESIGN DATA tr n / oil o il 79.2' 76. 73.6 1. ELEVATIONS SHOWN ARE BASED ON ASSUMED 0 0 A � ,A . w /�o..lC�. A .4 La4 r" soya Z/z + �t P 2. ALL PIPES IN THE SYSTEM MUST BE CAST IRON _ _ ___._ _ r �, !� ,oY? z!Z L'O',ar �. ,o,R �� /z" NUMBER OF BEDROOMS 4 78.1 r 7 n - OR SCHEDULE 40 PVC. -_- !� l3 Qy� AGE DISPOSAL N r GARB � + 77.0' 3. HEALTH AGENT/CAPE & ISLANDS ENGINEERING M 3 B W/ r,it � _*L'o y 78.2' �� \ v� �1' h MUST BE NOTIFIED WHEN CONSTRUCTION IS z ,o yR r/y DAILY FLOW 150 GPD, SEPTIC TANK REQUIRED 1500 GAL, COMPLETE PRIOR TO BACKFILLING. y 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED aa~' h•4.(`�"'" C1 SEPTIC TANK PROVIDED 1500 GAL. s�,�� LEACHING REQUIRED 440 GPD. 7 f 73.a BY CAPE& ISLANDS ENGINEERING AND THE BOARD ,oyIR 1!z_ sn.+4-! f OF HEALTH, �8.2' 78.6 8 s \ ,'" 77.7' 5. MATERIALS AND INSTALLATION SHALL BE IN ao" ______._____ y '"� spa " ` SOIL ABSORPTION SYSTEM CALCULATIONS: +y�fA., f S�o.sc n r COMPLIANCE WITH THE STATE SANITARY CODE g ,o 7/� /e _N \ [TITLE V]AND LOCAL APPLICABLE RULES AND sy _ ( 78 � - _ _. _ _. .�,-.: _�+ ,, �. , �, s.,.,a ,c o......r y SIDEWALL AREA = 186 SF. \ REGULATIONS. r ,o - - - - - - - - -- ♦ \ a h -_ �. , 1 t s><e„ ., 186 SF. X .74 G/SF. = 137 GPD. K o �\ \1 6. NORTH ARROW IS FROM RECORD PLANS AND IS wy x,i 9Z c. A F -*_ 4 • P v i r :�___ . .,... -_. BO . ,0. AREA S_ . / T ENERGY PURPOSES. .. . _ NOT::INTCsJDED FOR SOLAR E R r�ate.., � •► 76.6; 7• WATER SUPPLY. MUNICIPAL WATER SYSTEM. ,oyQ i6 441 SF. X 0.74 G/SF. = 326 GPD. f' y �/ e N N-HAZARD LEACHING PROVIDED = 463 GPD. 7 . / + \ 8. FLOOD ZONE C [ 0 ] 79 9' / / / / 9. FLOOD PANEL: 250001 0003 D DATED: DULY 2,1992 y NO GROUNDWATER zz2 NIO GROUNDWATER lee. 2ya NO GROUNDWATER 10. THIS PROJECT DOES NOT INVOLVE ANY PHYSICAL y - s'- 77.5'\ GROUND DISTURBANCE OR VEGETATION REMOVAL 8 . /. WITHIN 100' OF WETLANDS,INLAND OR COASTAL J. 6.0 I + BANKS OR FLOOD HAZARD ZONES. ,` 75.2' / I`\ / '� \ / CHRISTOPHER COSTA&Associates D , 1 G / /\ \ \ Land Surveyors•Civil Engineers a Environmental Consultantts o �7�,7 [ J / t- 465 Mai n Street/P O.Box 126,Est1 FaingW,,MA 02536 � .' Phone:5065486424 Fax SOe-546$424 7 . \p M1,' / rr. E-MAa CC4SSOCOCAPECOONET r ';, L� ��/ ' Mr.David C.Sanicid,PLS _ �I 76•V� \ Cape and Islands Engineering r `\ / ° Ma Falmouth Road,Suite 301C fP. f Mashpee.MA 02649 3 cr l RE: SIEVE ANALYSIS OF SAMPLES TAKEN FROM 1970 MAIN STREET WEST LEGEND / BARNSTABLE MASS.MAP 217 PARCEL,4 75 , �\ + f� 52 PROPOSED CONTOUR Dear Mr.Sanicki, 77.9 �\ ° S ,yam•.,,` �<� � � `• A total of three random samples were collected into one container from the Mbove _ referenced property. The contents of the container were air-dried and the sieve �'� --- -- analysis is as follows .s TIN CONTOUR 7 . �\ z , ..,.-_ a_ � / � \ SYSTEM UPGRADE 9 � \ eJ --- \.. +77.8, ,/ Sieve %Passing %Allowed %Remained(0.0.5% Pass/Fall ._ / ,< 4 45.5 45 -54.5 PASS.-. 40 / ! OBSERVATION PIT _ _ - A =' �. . PROPOSED SEWAGE DISPOSAL SYSTEM sa i°.3 10-10o zs.z Wass \,- "•w .- 100 2.7 0-_5 13:8 WASS 7 . - -- + 200 �<1.0 _ 0-5 -_ 2 PASS DISTRIBUTION BOX `S PREPARED FOR \ o ❑ `` . t X The reauas indicate the sod Is sortable under MGL 310 CMR 15.255 Fill Matte a fo „ ' 73.3 l� _ 75.3 >f rue v s.As. f ~ CAPE HARBORSIDE CONSTRUCTION CO.,INC o a o SEPTIC TANK '\ i Respectfully submitted, -- '-� HSE.NO. 1970 MAIN ST. RT 6A �. 74• SOIL ABSORPTION SYSTEM t a WEST BARNSTABLE MASS. , C ristopher Costa,PLS 1N es e ' ��y` O-/ DEP Certified Soils Evaluator ' RESERVE RESERVE AREA U4 GIST PLAN NO. 020804 SCALE: AS NOTED 22.26 PIPE INVERT ELEVATION _ "5 itt_ f •> T„\Y FILE NO. 412BA DATE: FEB.8,2004 SEPTIC FILE NO. 74 PCS FILE: mainst1970 VIA C.Jt{I :` I 'nun Y PLOT PLAN ...,.�.1� � -i'� CAPE & ISLANDS ENGINEERING z z z 1 SCALE: 1" = 20' o 0 0t.j<<t� 800 FALMOUTH ROAD SUITE 301C 217 14 A 1970 5 5 5 MASHPEE,MA 02649 (508) 477-7272 + MAP SEC PCL LOT HSE 70.6'