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HomeMy WebLinkAbout1170 MAIN ST./RTE 6A(W.BARN.) - Health \ V 1170 MAIN ST./RT. 6A, W. BARNSTABLE A= 178 015.CND ¢n( 0 4 v e � I Commonwealth of Massachusetts �•�Q -�S~ �°2 } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v— 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable t✓ Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites path Company rae Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes ```0��� �t1 OF'r s0,V/" 2. ❑ Conditionally Passes .. qc MICHAEL yN= 3. ❑ Needs Further Evaluation by the Local Approving Authority =o: SEARS No.SI14430 4. ❑ Fails ' o,: % TIF�� ' 8-3-20 Inspector's Xnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments « � 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c / 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N FIND (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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form +_ I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1170 Route 6A u Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is West Barnstable Ma 02668 8-3-20 required for every -- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more-rom a private water supply well". Methcd used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '•_ 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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. El E Any portion p Y ortion 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 water supply El ® 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or amapped Zone II of a public water supply well II t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t- u 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form l; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 f Commonwealth of Massachusetts :, p Title 5 Official Inspection Form 11 �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1170 Route 6A V Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Office BLDG Design flow(based on 310 CMR 15.203): 535Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 535 GPD Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: Well water Last date of occupancy/use: present Date Other(describe below): 3. Pumping Records: Source of information: June 20202 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 L Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . � 1170 Route 6A u— Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1985- #85-1168, D box 05, 2005-430 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts ,�,p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - p Y rY 9 u 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1. feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gal tank with both inlet and outlet tees, inlet cover at grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form - I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f<� 9 P Y rY !% 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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.): D box is 16x16 H2O cover at grade with 1 outlet pipe l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 cam, Commonwealth of Massachusetts �- : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1170 Route 6A Property Address Bridge Creek Professional Center Condominium-Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 5 flows at 26" below grade, clean and dry with no sign of failure 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 { c Commonwealth of Massachusetts Title 5 Official Inspection Form ,� p l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 1170 Route 6A V Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts : Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 1170 Route 6A V� Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 1170 Route 6A V Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable -Ma 02668 8-3-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check:Slope ® Surface water ® Check.cellar ® Shallow wells Estimated depth to high ground water: _ 15' feet Please incicate 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 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 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 coo, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 1170 Route 6A Property Address Bridge Creek Professional Center Condominium Trust Owner Owner's Name information is required for every West Barnstable Ma 02668 8-3-20 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. inspector Information: Complete all fields in this section. ® B. Cerification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3. or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 157 Explanation of estimated depth to high groundwater included G� q1 1I� M o Uc P-ow,d ►mad-.- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i •rev 7/6/2018 9 P Y 9 t5 nsp.doc 2 P f Jul 27.20,04,24p Capewide Enterprises 5084774977 p.3 7/27/2020 Assessing As-Built Cards I .1"OF BARNSTABLE L*_Z' [ON //7 SEVA M GH VL.LAGE a ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SE777C.7ANK CAPACITY LEACHING FACILITY:(type) (sue) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DAIS: Separatirm Distance Between Ihe: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If airy wells cxist I on site or within 200 feet ofleaehing facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ir-- I I i I /A fat I https:Jl17801502A&se =1 1/2 wevw.townofbarnstable.usiDeparments/Assessing,Property_ValueslHN1display asp.mappar= q WliON TOWN OF BARNSTABLE a 1170 C/ SEWAGE # VILLAGE �' / ��� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 `j&- d� 6 r 1 / 0 '1 � Jan 21 2019 20:04 HP Fax page 1 l77-g_ 016- DdLA Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I.a W 1170 Rt 6Ag Property Address ,,;, Bridge Creek Professional Omwf Owner's Name -' t information is West Bamstable ✓ MA 02668 1-11-19 f. required for every page. Gty/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. n t O F'l ln ````"nuh���� Un goutfarmsms A. Inspector Information �'/ �3��-�- �'��•filling out forms on the computer, James D.Sears • JA M ES use only the tab — — key to move your Name of Inspector c; cursor-do not Capewide Enterprises . �'-. C1, use the return Company Name ` � ' ���' key. 153 Commercial Street I N SP,�G���`�� Company Address Mashpee MA 02649 City/Town State Zip Code 505477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails ,sa- 1-11-19 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note; This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. 15lnsp.doc•rev.7/26/2018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Jan 21 2019 20:04 HP Fax page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form iSubsurface Sewage Disposal System Form -Not for Voluntary Assessments y 'P 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name Information is required for every West Barnstable MA 02668 1-11-19 per, City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: ® I 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 is a 1500 Gal Tank D Box and five flow's. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old'or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ NO (Explain below): t5insp.doc rev.7/26W18 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is required for every west Barnstable MA 02668 1-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken.settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine If the system is failing to protect public health,safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc rev.7261201E Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Z a6ed xed dH 6 6:5 6 6 1,0E ZZ Uel Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is required for every West Barnstable MA 02666 1-11.19 page. CityfTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is wifhin 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fall unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply, ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc•rev.7126018 Title 5 official Inspection Form Subsurface Sewage Disposal System-Page 4 of 16 £ abed xeJ dH 6 6:5 6 6 602 ZZ Uer Jan 21 2019 20:04 HP Fax page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is required for every WestBamstable MA 02668 1-11-19 page, CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in aseWmI is less than 6"below invert or available volume is less than %day flow o4-M NIA4 ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes".or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7126NO18 Title 5 Offldal Inspection Form:Subsurface Sewage Disposal System•Pape 5 of 1s L_ Jan 21 2019 20:04 HP Fax page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form <T Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1170 Rt 6A Propery Address Bridge Creek Professional Owner Owner's Name information is required for every West Barnstable MA 02668 1-11-19 page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner.or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must Indicate"yes" or"no"for each of the follo wing for all inspections: Y g p 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. El ® 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)] 15insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface sewage Disposal System-Page 6 of 18 Jan 21 2019 20:04 HP Fax page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r� 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is every West Barnstable required for eve MA 02669 1-11-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date l5insp.doc•rev.7W2018 TRW 5 Orficlal Inspecdon Form:Subsurtece Sewage Disposal System•Page 7 of 18 Jan 21 2019 20:04 HP Fax page 8 Commonwealth of Massachusetts J Title 5 Official Inspection Form RSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owners Name information is every West Barnstable required for ev MA 02668 1-11-19 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) 2. CommercialAndustrial Flow Conditions: Type of Establishment: Office BLDG Design flow(based on 310 CMR 15.203): 535 Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): 535 G.P.D. Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available; Well Water Last date of occupancyluse; Present Date Other(describe below): 3. Pumping Records: Source of information: Yearly Pumping Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t6lnsp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system.Page a of to it r - Ian 21 2019 20:04 HP Fax page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is required for every West Barnstable MA 02668 1-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy. ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1985 Permit#85-11681 D Box 2005 Permit#2005-430. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2'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.): _Pipeing is 4" PVC SCH 40. Wnsp.doc-rev.7/2612016 Title 5 MW Ins lion Form:Subsurface Sewn a Disposal pec g System•Page 9 0l 18 Jan 21 2019 20:04 HP Fax page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1� 1170 Rt 6A v� Property Address Bridge Creek Professional Owner Owner's Name information is required for every West Barnstable MA 02568 1-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 14", feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-20. Sludge depth: 31' Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness ill Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Asbuilt-Tape Sludge-Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 14"below grade w/inlet cover,steel at grade in black top. Inlet tee,out let baffle. No sign of leakage or over loading Out let cover under black top t5lnap.doc-rev.7/2 612 0 1 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 16 Jan 21 2019 20:04 HP Fax page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name Information is required West Barnstable required for every MA 02668 1-11-19 page. CitylTown State Tip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑other(explain); Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 15insp.doc•rev.7/2612016 Title 5 Official fnspection Form:SOsurrace Sewage Disposal System•P"11 D(16 i Jan 21 2019 20:05 HP Fax page 12 Commonwealth of Massachusetts �k!v Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 11 TO Rt 6A Property Address: Bridge Creek Professional Owner Owner's Name information is required for every west Barnstable MA 02668 1-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): 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 cf leakage into or out of box, etc.): D Box is 20"x20"-2' below w/steel cover at grade in black top. Box is clean and solid w/one line out. No sign of over loading or solid carry over. 151nsp.doc-rev.7128/2018 Tile 5 Official Ins pection Fonn:Subsurface Sewage Disposal System•Pege 12 of 18 Jan 21 2019 20:05 HP Fax page 13 Commonwealth of Massachusetts g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f k 1170 Rt 6A Property Address _Bridge Creek Professional Owner owners Name information is every West Barnstable required For eve MA 02668 1-11-19 page, City/Town State Zip Code Date of Inspection D. System Information (coot.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ 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. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explaln why: Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Dlaposal System.Page 13 of 18 Jan 21 2,019 20:05 HP Fax page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments �� 1170 Rt 6A Property Address Bridge Creek Professional Owner Owners Name Inforrnatrequired for is West Barnstable required for every MA 02668 1-1 t-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is five flow's w14'stone. Flow's at 26"below grade Wone steel cover at grade in black top. 2"water in flows. No sign of over loading or solid carry over Wall's and stone clean 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): tbinsi rev.MUMS Title 5 Otlicial Inspection Form;Subsurface Sewage Disposal System•Page 14 cf 18 Jan 21 2019 20:05 HP Fax page 15 Commonwealth of Massachusetts Title 5 official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v ' 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is every West Barnstable required for eve MA 02668 1-11-19 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 13. 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.): 151nsp.doc rev.N612016 Title 5 Oflicial Inspection Form:Subsurface Sewage Disposal Slstem•Page 1s of 16 Jan 21 2019 20:05 HP Fax page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments may' 1170 Rt 6A V Property Address Bridge Creek Professional Owner Owners Name iequired;fore West Barnstable MA 02668 1-11-19 required for every page, CitylTown State Zip Code Date of Inspection D. System Information (coot.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i�EAP A 1 A-a= 3y', R-A = A0 A � o 13 Glnsp.doc•ray.712612018 Title 5 Official Irepection Form:Subsurface Sewage Disposal System-Page 16 of 18 Jinn 21 2019 20:05 HP Fax page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1170 Rt 6A v Property Address Bridge Creek Professional Owner Owners Name information is required for every West Barnstable MA 02668 1-11-19 page. City/Town Slate Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to high ground water: 1 feel 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: 7-12-85 Date ❑ Observed site(abutting propertylobservation 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: T.H.on Design 7-12-85 no G.W.AT 15' Bottom of flows at 4' Bottom of flows 11' above T H Depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev,712EI2018 Title 5 OtWal Inspection form!Subsurface Sewage Disposal System-Page 17 of 18 JAn 21 2019 20:05 HP Fax page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is required for every West Barnstable MA 02668 1-11-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed&Dated and 1,2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D.System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 1 d rem A v 6-u/, ftsp.doc•rev.7126/2018 Title 5 MUM Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates-(cost$40.0.0-fo.r 4 ears). A business certificate ONLY REGISTERS YOUR NAME in town (w.hich you must do by M.G.L.-it does not give you permission to operatemust first obtain the necessary signatures•on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601. (Town Hall) and getthe Business Certificate that is . required by law. DATE: a Fill in,please: i1 :.y tl::?:�4!=•',LI`41(11`rV'rp,1,y1Er`117i - :� ; .. �yrCJ i;I_.,Y�;;��f��;4���;1 O' ".+.-•'.'x •'�TU, � APPLICANTS YOUR NAME/S: ''!' 5i BUSINESS YOUR HOME ADDRESS: WAe Y`' 'IL'�`�t�'�'�'!,I TELEPHONE # Home Telephone Number �-1 L4 fl R Ll I -a-a-3 i i;.J� .L•'� my d E-MAIL: s t�� C-( P�c�lr W1 NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS Cjx y� '�`'�— JU :� I IS THIS A HOME OCCUPATION? . YES NO WA- Ua lobS� � � ADDRESS OF BUSINESS I.I-70 YYIGi-kin S 4 WGS'r- �c�✓�5 �2 MAP/PARCEL NUMBER [Assessing). When startipg a new business-there are.several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST, GO TCL ain 5 . (corner of Yarmouth ' Rd. & Main Street)-to make.sure'you have the appropriate permits and licenses required:to legally operate your business in this town. 1 BUILDING COM IS ION R'S OFFIC This individu I he n nfo e of y pe i *ei e ' pertain o this type of business. th rized Signat a** 1 COMMENTS 2. BOARD OF HEALTH This individual has bee i� r ad of the permit r uirements at pertain to this type of business." Ize Signature** COMMENTS: 77 3 - CONSUMER AFFAIRS(LICENSING AUTHORITY This individual has been informed oftha'licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: . I gay 041510:46p p.1 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A < Property Address Bridge Creek Professional Owner ` Owner's Name information is :r.• required for every West Barnstable MIA 02668 4-30-15 page. Cityrrown state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important?When A. General Information filling out forms i j 13 ��SH�OF pluii���� on the computer, 'qs %, use only the tab 1. Inspector: key to move your o?� G cursor-do not James D. Sears =R: JAMES ,m use the return Name of Inspector key.Vt Capewide Enterprises,LLC * ' *'! •, 0; 9 Company Name —WAi,�r�''� ����i F 5•I N SP�G```��� 153 commercial Street �'��rrraul►Iei►w'�� Company Address — — �, Mashpee MA 02649 Cityrrown state Zip Code 508-477-8877 S1623 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 5-4-15 spectors 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. Mai;-3113 Title S011rmal Inspection;=orm:Subsurface Sawago D"al Syslam.Pg.1 of 17 May 041510:47p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information required for every West 8amstable MA 02668 4-30-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is.a 1500 Gal. Tank D Box and five flow's, 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 Q N ❑ ND(Explain below): l5ins-W13 Tdie 5 Of oal Inspection Fomr.SLbsurrace Sewage Disposal System•Page 2 of 17 May 041510:47p p.3 Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owners Name required Information is West Barnstable MA 02668 4-30-15 required for every page. Cityllrown State Zip Code Date of inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpstalarms are repaired. B) System Conditionally Passes(cunt): ❑ 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 Oftal tnspedon Fom Subsurface Sewag e Disposal System•Page 3 of 17 May 041510:47p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is West Barnstable MA 02668 4-30-15 required for every page. Cdy/Town State Zip Code Date of Inspection B. Certification (cons.) 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 ❑ ED Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in ess�ee*is less than 6° below invert or available volume is less than '/Zday flow /-EAC/,///y t5ir!s•3113 Trite 5 Official tnspalon Form:Subsurface Sewage Disposal System•Page 4 of 17 May 041510:48p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is required for every M West Barnstable A 02668. 4-30-15 page. CityITown state Zip Code Date of Inspection B. Certification (cunt.) Yes No 0 ® 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•3M 3 THIe 5 OfWal fins pection Form:SUDsuAaoe Sewage Olsposal System-Pap 5 or 17 May 041510:48p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name informationis requiredairedfor every West Barnstable MA 02668 4-30-15 for 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 NA) ® ❑ 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? ❑ 0 Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins.3113 Title 5 Official Inspection ram:Subsurface Sewage Disposal System-Page 6 of 17 May 041510:48p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional owner Owner's Name information fo required for every West Barnstable MA 02668 4-30-15 page. Chyrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and five flows. 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 information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Comwerciallindustrial Flow Conditions: Type of Establishment Office BLDG Design flow(based on 310 CMR 15.203): 535 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 535 G.P.D. 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: Well Water [Sins•Yi1 Title 5 Wool Inspection Form:Subsurface 39mge Disposal System•Page 7 cf 17 May 041510:49p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner owner's Name information is West Barnstable MA 02668 4-30-15 required inr every page. cdyrrown State Zip Code Date of Inspection D. System Information (coot.) Last date of occupancyluse: _Present _ Date Other(describe below): General Information Pumping Records: Source of information: Yearly Pumping 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-3/1 3 Tide 5 0r6dal Irtspecbon Fotm:Sabsuriace Sewage Qisposel System•Page 8 of 17 May 041510:49p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owners Name information is required for every West Barnstable MA 02668 4-30-15 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: 1985 Permit#85-11681 D Box 2005 Permit#2005-430. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Pipeing is 4"PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-20. Sludge depth: 1" 15ins-WU Tine 5 OfWal Inspection forrm Subsurface Sewage Disposal System-Page 9 of 17 May 041510:49p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is required for every West Barnstable MA 02668 4-30-15 page. Citylrown 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 NA Scum thickness 1" Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 14" below grade wfrnlet cover,steel at grade in black top. Inlet tee,out let baffle. No sign of leakage or over loading. Out let cover under black top 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 [Sins-3113 Title 5 Official tnepection Form:Submffface sewage Disposal'System•page 10 of 17 May 041510:49p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is required for every West Barnstable MA 02668 4-30-15 page. CitylTown 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 L] No bins•3113 Title 5 Off id Inspedon Form.Stsurfaoe Sewage Disposal System-Page 11 of 17 May 041510:50p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is West Barnstable MA 02668 4-30-15 required for every page. Cityf town state Zip Code Date of Inspection D. System Infolrmation (cunt.) 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.): D IBox is 20"x20"-2' below wlsteel cover at grade in black top. Box is clean and solid w/one line out No sign of over loading or solid cant'over. 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: tSns-Y13 We 5 Ofrioiel Inspection Forst Subsurface Sewage Disposal System-Page 12 of 17 May 041510:50p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name required fn is West Barnstable MA 02668 4-30-15 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number ® leaching chambers number. 5 ❑ leaching galleries number: ❑ leaching trenches number, length: -- ❑ leaching fields number.dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Typefname of technology: — Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is rive flows w/4'stone.Flows at 26"below grade w'one steel cover at grade in black top. 2"water in Flows. No sign of over loading or solid carry over. Wall's and stone clean. 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 t5i ns•3113 Tale 5 official hasped=Fomr.Subsufece Sewage Disposd System-Pap 13 of 17 May 041510:50p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form ktt:w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Properly Address Bridge Creek Professional Owner Owner's Name information is West Barnstable MA 02668 4-30-15 required for 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•3113 Tiee 5 Official Inspection Form:Subw6ace Sewage D sposal System•Page 14 of 17 May 04 15 10:51 p p.15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1170 Rt 6A ---- _._._---_.-....._.___._.._....._.----.--.-- Property Address Bridge Creek Professional Owner Owner's Name reformation is West Barnstable MA 02668 4-30-15 required for every — _ page. City1rown State Zip Code Hate 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: 0 hand-sketch in the area below drawing attached separately r 1-0 a f3--3 3 ,g) f i `SirIc•3M3 Me 6 Oirrdot KSPeoson Fom[Subsurfem of sposa:System•Page 15 of 17 May 04 15 10:51 p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address Bridge Creek Professional Owner Owner's Name information is b1res'Bamstable MA 02668 4-30-15 required for every page_ Cityrrown State Zip Code Data of Inspection D. System Information (cant.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallcw wells 0 Estimated'depth to high ground water 15' 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: 7-12-85 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: T_H_on Design 7-12-85 no G_W.at 15'_ Bottom of flows at 4'. Bottom of flows 11' above T.N. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3M3 Tale 5 Ofnael Inspection Form:Subsurface 9aUi sal System•Paga 16 0!17 May 04 15 10:51 p p.17 Commonwealth of Massachusetts Title 5, Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1170 Rt 6A Property Address: Bridge Creek Professional Owner owner's Name information is required for every West Barnstable MA 02668 4-30-15 page. cityrrown 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 OfF o tnspecKon Form:SubWace Sewage Disposal System•Page 17 of 17 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[pplication for Mt9;po9;a1 *pftem Contruction Permit Applic tion for a Pe t to Construct( . )Repair( ✓)Upgrade( )Abandon( ) O Complete System Individual Components Location Address or Lot No. 1 I_7a P C_10k ?fa 4 Owner's Name,Address and Tel.No. Assessor's Map/Parcel ,r1 d, 8oX -Zd4ol C� A r,?Lv e4, M A dA 1,3 l Installer's Name,Address,and Tel..NCi. Designer's Name,Address and Tel.No. 5? Y14uo r^LbC r'%JYLd b0rl c�:rrhe.a-v"�i Type of Building: Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder( ) i Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (-e I I Skjb0kh h6 X 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 Certifi- cate of Compliance has been is 's Ulealth.,SigDate Application Approved b Date Application DisapprovePor e following reas&V 'ermit No. Date Issued No. v` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2ppfication for Oigogal *pgtem Congtructton Permit Appli tion for a P. t to Construct( . )Repair(✓)Upgrade( )Abandon( ) O Complete System U Individual Components Location Address or Lot No. ner's Name, ss and Tel.No. (s�.Bur s b � e m�� Assessor'sMap/Parcel r<r v i SJ;?!, hi* 1'3 _,;1,3 / Installer's ame,Address T 1. Designer's Name,Address and Tel.No. SY.40 rrll�e�a`�x�dton ccn-hea-v'li(� �. oa(o3a Type of Building: i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day,,.Calculated daily flow gallons. Plan Date- Number of sheets Revision Date -� Title .� Size of Septic Tank m Type of S.A.S. Description of Soil; Nature of Repairs or Alterations(Answer when applicable) rCAQU H 20 `D15fr1bCA0h b0)( 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 Certifi- cate of Compliance has been issi5e -thi Oprd of ' ealth,A Sig S ---r tl) © ✓ Date • Application Approvedbt' O t Date x Application Disapproved for the following reasdn t }. :Permit No. Date Issued '1 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THI§lS,,TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (`� )Upgraded Abando ed( )by ���1 C0 1 . C�W 5o'1 at"',I1© (9+.&0, / VQ constructed in accordance with the prro isioris o fiTitle 5 andathe for Disposal System Construction Permit No ated ' Installer 10 , 1�b'�O U J. Desig r The issuance of this$ C s a nst ued as a guarantee t at the syst t 1 f c Ion-as designed. Date Inspe L No. Ql.�`J _1��-----�-----=------------ Fee - THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mtgpont *pgtem Congtruction Permit Permission is-hereby granted toConstruct( )Re air(� )^Upgrade( )'Abandon( ) System located at 1 )7 4 R '. (P a • t� O-r`Yl 1 Cl� , r and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions`. Provided:Construction must be c 4 lete w'thinxhtee years of the date of..this rmi . Date:_ `' Approved by 61S , JUL 2 1995 i DEpT DATE: 6/30/95_ _ wy TM I '=•PROPERTY ADDRESS:_-1170 Route 6A ECEIV ID --- West Barnstable,Mass _— 95 02668 - of DEK BARNS�p� ; On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . -H20 500 gallon septic' tank. i 2 . 1 -H2-0 �tstribution box. 3 . 5-H2O 8 'x4 ' Flow diffussors . Based on my Inspection, 1 certify the following conditions: 1*-, .- `h-is is a title five septic system ( 78 Code ) 2 . The septic system is in working order at the present time.. recommendations 1 . Broken distribution box *rust be replaced. _ I f i SIGNATURE'— Name: J.P.Macomber Jr Company:_ J.P_Macomber & Son Inc. Address: Box 66 ------------ Centerville,Mass . 02632 ' ------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY .�Z I JOSEPH P. MACOMBER & SON, INC. � Tanks-Cesspools-Loachf folds Pumpod & Installod ; Town Sower Connections - P,O. Box 66 Centerville, MA 02632.0066 .775-3338 775-6412 �. i 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM Address of property 1170 Route 6A West Barnstable,Mass . Owner' s name Art King Date of Inspection 6/30/95 PART A CHECKLIST Check if the following have been done: vF& Pumping information was requested of the owner, occupant, and Board of Health. YPG None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. YRG As built plans have been obtained and examined. Note if they are not available with N/A. YP The facility or dwelling was inspected for signs of sewage back-up. Yes The site was inspected for signs of breakout. Yes All system components, excluding the SAS , have been located on the site. Yes The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Yes The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. Yes-The facility owner (and occupants, if di.fferent from owner) were provided with information on the proper maintenance -.of SSDS.' r 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ` SYSTEM INFORMATION /1 FLOW CONDITIONS If residential 0 _ number of bedrooms 6 number of current residents NO garbage grinder, yes or no' NO laundry connected to system, yes or no NO seasonal use, *yes or no If nonresidential, calculated flow: 8A See Sheet 8A Water meter readings, if available: Present Last date of occupancy Office Building GENERAL INFORMATION Pumping records and source of information: Pumped Annually for the Past Four Years. Maint only. J.P.Macomber & Son Inc.. NO System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Yes Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy YES Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) None Pirst time inspected Approximate age of all components. Date installed, if known. Source of information: 10 years old. Sheet 8B NO Sewage odors detected when arriving at the site, yes or no r��_ "�') .p r.wf-� ��• ` k�r �•l./�1 1..� l..7 �.,��?•"'l��I�.J x".s f�'!q;_. •C.-r1A).G�i % �••---�.�.e �rill 1'�ch�;>;, : '' ���.�• ...-ter^�,�•�"" .r...�. . Y.t f b'�' ' r'• J �•���%':.�KP;'*Y�i••tl;tiJ�N!r`�2�'�� � '��i.^!'Q !Ji''+„1�/ ` ' ,[ .1 ( (.:�C11J4���✓ Y '"• s t .J l�t�1 S�l� r . L f t � G��'q s ► <'�,�! �al.r�.���.� ; )94�f•"�y1 �• �\ •,�-r�/:�r��il•�� cam' '1rQ L.. ,; �,n�� 1 .P!',. S .�'�,•• ,tom;�`;��^'t„�.k^•"�.;"�.' ' �i, �a ,,��"If'�f""��`� VG?r ir'1/. ;��, ti r.��; l , .. ( S` vL t .,,�� p i F `yam! .. - .. 1• y)i Tj7�x�F . l •�. v''�Lj ,r \k. {' .:cif ��la •a �� .. `}r�J�,�c •f a N^'�I!'Y �Y r,`��ly ti i � � f `t � l ' t{` 1 '�'�j'Y'. a -S: t I ./"s�i r ! •a .. �'�i..: _ sA fro.'•�q4.: • � : cam.-�r��,��, 1��, 1� �.���j�� . ' t=�;� ` ` 1 1 �,• 1 n 1�' .1R Lr/^} '"•^_"'t',`^ :{. a 1 .7.�1�t vy�a• I NO .T`• y!f -•+'41+: 2�yb' ;..wit• �,� b . .,. _ _ �. � � 'A - t�,�,,. �� �f`2� r�+a4 \ rp r s Cr ty •+ !' r41 l:'�i;. .�+ ... .Yr •r•i�.,,a 5 I^ yy,��.i� t��y ` Y I, � .c r} ft,. '^��r ` �j Fri 44 '+ 'y _x� y{ .:���ss�� r. r4��Y � \ .-_'�.� R { f �.ri�'..lp y.• MIA. '+''S�«�4'I►�i. sr ;'�y�' P .e+.l{ r'r- t �r t x ..•1 L .1 I- , y4`�� ��-, 'r'. ; � ;' 9a t.. .t � i - '1. ` �i � < .' „� r j3•air 1.;,�•'1 ,t , �, .�,,, ti r e• y��+-i r w.r t .a f °7''�[q't `"til i'M'�.,'„rir' '', •'� y Ei.•t a, � 's rY'�v. �� f.- r `;a Y} a�py,'t •..;�' t'i i wu I'A, Mb�hS,: p " "MR y'7? ��'. dam' +. ` y+` aei »' '+ ��'N; l} .� ! a ,es• y� � t :• .r . w.�L �y��� r f+ ',.>•• •.!� fc� y� I f 1�i.'.� 4�.t �!�'�'�� � � e.� F .I' •L �n a,\ '9'�.: 6'�•8't4`P�'•r\�fa #.Ci '. #'ai}�. f.'•� as 1'.,J " :.L"„' {x �`�. p 1 (�(+. �a r• .1 d C� � �\y`9��'G.',.,T .adl.�'�1 r-tia ri. :.ys 'A i P .fit as �a�r?a`/yc�•�JS••`7�' -,r�r�`w�Sbs �`.s(�' J^.v(r�:•f.,\ SY �7 r d'' / > > AYf'.'; iiM'•t�., �S �.�Ry •.�+�� - �5•.f".f� R9\`4 rSl+r . .•�• Vrt, }7' }�'i��R�y�il.' � N�' * .•�. h�'�r(c;M1� f^^.•r"r 1 y (' ,t?v is a. t `r �'•�•{ •lY•,rrif Y'J" t ) t �1 P Y' 1 } ) ,f�/ '• A� V•'ti N r.. - �.}]y•� .h c,- IT. •L..t.. 9 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: 1500 (locate on site plan) depth below grade: on surface Cast iron ring & cover. material of construction: XXX concrete metal FRP other(explain) dimensions: H=517" L-1016" W-518" sludge depth 14l'_ distance from top of sludge to bottom of outlet tee or baffle 1 " scum thickness 3" distance from top of scum to top of outlet tee or baffle 17" distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet. invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) Pumped septic tank annually,Tees in good condition, 4 ' 6", liquid depth. No evidence of leakage. Tank is fine no repairs needed DISTRIBUTION BOX: YES (locate on site plan) NO depth of liquid level above outlet invert-- - Comments: .(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) Distribution box is broken, Must be replaced, Yes Lidence of leakage PUMP CHAMBER: NO (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, . recommendations for maintenance or repairs, etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ) PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : VFC (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits and number leaching chambers and number 5-flow diffussors 481x121 ; leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) No Hydraulic failure, see Sheet -1.1)A CESSPOOLS (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 i inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, 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,. recommendations for maintenance or repairs, etc. ) . �� �l.Cz.Ur Qt.J• i• � �,� � sJ t.l > >`�'E'L,°" �t�� : 1b�'��'.+j`�'. 1C�Cw.-r-i ~ `tt+-lb"-afy��.� t } •k't�'�`r�' � f (h` .`'.� � '. �( � :V�,T ,�;fn-. 1. � •� t .r a..�'.r Q.�> t;...dT ^`Y - "vt.11�►-�1.'._ :��p+:.1-=���14�+=� ��"-•:-�-: '; C'Y�kSr i.;�4. - e .JC...:>x�__.}�=-�.�.,:. �a1�;:ti..� .C.:ta..�:;'� �':rJ�-�1�e..1��!Z--.►•4..kr•.:• � _ a r FY ' k • - - � •. �,�w��."'�r^.., y, N�n.w..N. Mal lJ.�`iy�� ki gal `,�.�.... :•'�'5���a�'�T� - • '.., �;�i lei /��'�:...�� �`�••�2K :.�J�A '•rI1�J.:�6��'2;5� � ��—�: .' ,�,�;"','i?� ,�W�O,� /���r'l�f •II'�_ _''��I!l'� f'..'�'/ L/ �1`.�//�`l x} b,f S7�t��r. ..+`�oS.Via'• .. : .. �_;fr'��� r` :• �.,• 4 '� .rk. tip} '•;t. �t''��,,'. '�k?Y,�,, •C. '� _s.,rn��vv�?`ca1�';:. `�'7'"�,��,. :�... ..,.s.....- i i i rf• !L .:T. �.�•� '-taG.a+IJ•.7' Ly1 ,. l l�"J 1, �p '�_'•� � •''�`.��. ' i�Y .,r�Y ' '; '4 '��f✓1 s (S.l J.�L1.�i ' �, L. �: i'.. ;'�`; -,,� i F�y'r�. ._L t ! Y '.,,�•' .., .�., .3 „ �t� i y.. � �1q F",�j; ^'7:ily �.n• �. 6U$F, A,FACE SEWAGE D28F65AL $YB ,... :PAR tW 'sysTEM -INFO T von LiD�B AV �, `.• '' 'GH aF `SEWAGt­ Z 7SPOSAL SYSTEM: tips to at. least two permanent, erey-0s.1' .W.-,dma: anchmarks Pj � �r oil,,all wells within 100 ' IT ;; it �•..•... , _. 4. YJ IA:TO TER depth t roundwater of .determination .or approximation'; r _ .... 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) -o Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Nn Static liquid level in the distribution box above outlet invert? ' yFC Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? NO Required pumping 4 times or more in the last year? number of times pumped NO Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: NO below the high groundwater elevation? NO within 50 feet of a surface water? NO within 100 feet of a surface water supply or tributary to a surface water supply? NO within a Zone I of a public well? NO within 50 feet of a bordering vegetated wetland or salt marsh- (cesspools and privies only, not the SAS) ? NO within 50 feet of a private water supply well? NO less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water anal, ) . for coliform bacteria, volatile organic compounds, . ammonia nitrogen and nitrate nitrogen. TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION �xr.:tsc�e.s:�r zsrr't�y-eyr.�src�, aT-estrtvcaae_.osac3a•'.�sat:-ttta _ —TYPE OR PRINT CLEARLY— �.ss+rrarsx:+sasrscrsrrTr_rva.er"�z' PROPERTY INSPECTED STREET ADDRfZS 1f'70 Route 6A 'Test Barnstable,Mass. ASSESSORS MAP, BLOCK AND PARCEL # OWNER NAME UNK PART D - CERTIFICATION �- NAME OF INSPECTOR J P Macomber Jr COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville Mass . 02632-0066 Street Town or City COMPANY TELEPHONE (508 ) 775 - 3338 state ZIP FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT —z I certify that I have, personally inspected the sewage disposa-1 system at this address and that the information reported is true, accurate , and complete as of the time of inspection . The inspection was performed recommendations regarding upgrade , maintenance , and repair are consistentny with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : XXXX System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature t t • �'<< Z - Date /v s�srssssss; t � One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall u pg within one year of the date of the inspection, unless alloweddorthe requiredm otherwise as provided in 310 CMR 15 . 305 . partd .doo r Water Conservation SAVE Tips . . ME! CHECK FOR LEAKS Water Loss in Gallons Due to Leaks Leak this Lotl q Loss Per Month Size 3,600 360 10,800 • 693 20,790 • 1,200 36,000 1,920 57,600 ® 3,096 92,880 .0 4,296 128,980 ® 6,640 199,200 6,9.84 200,520 8,424 252,720 9,888 296,640 11,324 339,720 0 12,720 381,600 14,952 448,560 6.. n Ccmmenweann or Masscc^usens Execurive Office or Environmemcl Altars Department of Environmental Protection Wc7ter Pollution Cenrrol Tecnnicel Assoence and Training Secrions Wnui.m F.WOW Trudy Cox• ECCA Thomas 8. Powers 06%1">%9� TTN : Joseph P. Macomber, Joseph Macomber and Son PO Box. 6 6 1 I Dear Joseph P. Macomber, Jr. , I am pleased to inform you that you have attended training, met the experience qualifications, and have passed the Title 5 System Inspector exam, pursuant to 310 CMR 15 . 340 . The passing grade for the exam was 39/52 or 75% . Your grade was 81% . This is an official notification that you are a Certified Department of Environmental Protection Sysr-em Inspector pursuant to 310 CMR 15 . 340 . You will receive a Svstem Inspector certificate at a later date . �L you have a!1V =uuller _ - .ecIse '::rI tc ;ne ar. r.' e -r 1_ lowing address : "imba11 Sin!I �G!: !'ilanr, you very iiluch for Sincerely, Slill_:DSOn, I� tf7� Routs 20 • Millbury, MA 01 7 • FAX 5C3-755-92-3 • Tulapnon• SC&-75Er-7291 eX����w � d��w, G t - r.. w )* t f_ . ., �. r _.. �: t.+. ♦_ 3 4 ,.. . ., _ `` ` , t` � V; F r n..1 � 4t� _. .,._� �� f 1 � � _ � ' .L �f + ` 3 + f t ,4 y.e f • A` ,Y J �, • • 1 r 362-4541 926 main street yarmouth mass. 02675 down cape engineeiift f civil engineers&land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys site planning sewage system designs May 5, 1986 inspections permits Barnstable Town Hall Board of Health South Street Hyannis, MA 02601 Gentlemen: Please be advised that Down Cape Engineering inspected the septic system installation for Mullin/Taylor property located on Route 6A, West Barnstable. We hereby certify that the installation complies with the intent of our site plan #85-330 dated November 4, 1985. Sincerely, 1 Arne H. Ojala' O AHO/cdw ' MAP N0.1. l l�5 PARCEL ,v YtN J(Y S E G E PE VILLAGE (� li90 :1,oINSTALLER'S A E i ADDRESS �qlz- 0 U. 1 L D E R OR OWNER DATE PERMIT ISSUED Z 7 � DATE COMPLIANCE ISSUED 19 i �. y I 1 13 /67O.D - (Sv 0 ) 7s ��P y r a3)Z9��e. r r \ ly No..�S.-.T . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratiun for Disposal Works Tonotrurtiun Permit Application is hereby made for a Permit to Cons t ct ( ) or Repairr�( ) an Individual Sewage Disposal System at: 'IT /tAlx) ALA ..........�c9�.S-► -....RA.�- kos.:r�0%r.�-�--............................................ ---------------------=�.. •......................................... Ad -A LLA- ,j o�-��/1/�e!![ /....g�11..G or Lot No ................... . ... . �_ .> �8r�,.r,� ...x..>.:� Ow er j Address a •--. G.......... .......................................... .............................. Lit%cl,O --`S Installer Address Type of Building Size Lot__13f.7.8K.......Sq. feet U Dwelling—No. of Bedrooms......................... .....Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type e of Building ��l�� fir YP g ..9No. of persons---------------------------- Showers ( ) — Cafeteria ( ) p' Other fixtpres ............................ W Design Flow...1�6AL ..1 Et........gallons per person per day. Total daily flow.._....�J -�.......................gallons. WSeptic Tank—Liquid capacityJ5 gallons Length...t k.. Widths_!�i..... Diameter................ Depth. {' x Disposal Trench—No. .................... Width..... Total Length..._�.6....... Total leaching area.._`��..___.T.._....s9/ft6i 3 Seepage Pit No----------_---_-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by.../A _..Q.�iO�?0.....� .*................. Date..J.V(,Y... fa 9 �� Test Pit No. 1.......Z....minutes per inch Depth of Test Pit.... - .... Depth to ground water...U............... 44 Test Pit No. 2..--Z-...minutes per inch Depth of Test Pit...... L...... Depth to ground water....`��?."............ 04 .....................•-•--........-----........_.............••--•--...--•-----................_.......................••_..... Description of Soil.�..I....Q-` '�_: r�i''?. .ELT � '.�.32� 3. ✓. G . .t.Z ad.............. ... 0 Nature of Repairs or Alterations Answ when applicable... -�1 �n l :........ ---•--. - �--.._ ....-- ,,ee�� n� .-, _.._. �?_c tYn_ . ill. d .._ s ----.tom----- D!1..---..:.._�._..-_�'Y!----------- ----- -...._.......� Agreement: a cc3 r_ � -�g l2. The undersigned agrees to install the aforedescribed Individua Sewage Disposal System in accordance with the provisions of LITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n • sued by th rd o health. Signe ... .. .. ............. . . ...................... ........ ..1_. --•--•- � �.�.. Da - ApplicationApproved BY-- --. . .... ...............•--.......-•--•---.....-----.....---. ..._......_......._ .�.............. Date Application Disapproved for the following reasons:................................................................................................................ .....................................................................•-•-•---........_.........---:........._....----••-•••-•-•-•---•-•......._....._........•••...•----••................... Date Permit No...... ............... Issued.....................................•.................. Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH ' ............ ...OF..... >'Aa-:SA � ,.: '.... .... ::...._.......:_. Applirtttion for Disposal Works Ton#.rudion thrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an'Individual Sewage Disposal System at .................= ' ...«..B.............� - 2 � : C3 ...... .. .......•...•.... Un �� �ocatiorn-Addresss� q 'l or Lot No /owner Address a ...r... -•-••••---------•-•.._...•-•••••.........- .......................................•- •.. . • ........................... M Installer Address 4 2 9� Q7i Type of Building Size Lot..........................Sq. feet V Dwelling No. of Bedrooms......................... ...._Ex Expansion Attic�--� g— •-••;-�'•--.-.• p ( ) Garbage Grinder ( ) aOther—Type of Building .. �'r ....... No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures •... ..................... -•----------•--. W Design Flow. �s G'±A ..�� .Z....gallons per person per day. Total daily flow..-...-.'55_---3:5..___...................gallons. WSeptic Tank—Liquid capacity 5 gallons Length.. .. Width.5..! ..... Diameter................ Depth..'t.FF Disposal Trench—No..................... Width..:.a�.......... Total Length.....'.�:.A....... Total leaching area..9�Q'.......s �ftef-1 D x �• 3 Seepage Pit No..................... Diameter...:...:'V........ Depth below inlet'.'.....j.....L..-Total leaching.area.................sq. ft. Z Other Distribution box ( �) Dosing tank ( ) ! '" Percolation Test Results Performed b ... !? . .�'?%�!� �A... _R.E*r Date..JUL*.•. lZ, #�$S � 4 y ... 3........ ....... %ii a Test Pit No. I....... ...minutes per inch Depth of Test Pit....�_�':.... Depth to ground water..`. ............... 44 Test Pit No. 2._GZ-r....minutes per inch Depth of Test Pit.....191 ... Depth to ground water... ............ a •••................................................ ..........- -- ....._.._...... O Description of Soil..... --•- -`�-�f t� (4AIn I S'1�Zat, ZAlr 132 43q(X,A-, CLAq : t 3Z'Wf ...................................................................... U ►., _....__# ?_ l7 7,4�`'-.t,DAi?'t -SU6501t�_ , ?*" ` #Z.t" SC OA/v V Ct.sgI t // +� / ,t �...A y^ /p J(� '�j t . , �...................•-----...............-•----•••...........-•-••••...... W 1 7,(!�•« ..� ,Io�'....C,.,0A(Z_�-.._r]Ak,.'`0.. A 7ka��..............................ft 8C.J1JL� 4 +�A ' ••••.......................... ................ UNature of Repairs or Alterations—Answer when applicable 1d S?S t?''}"-�.....E_r)-7:r^f�(- ��/i� .Ir- 41..J1 _l•'.., c�.Ea r !�t� '1 _ l\.r Y�t1r1 `mil Vid PY1C A(ti- Y.,_�!�S t— -j•'7(" �• The undersigned agrees to install the aforedescribed Individualewa a Disposal System in accordance with AI eement: �� r : l a C< -� - g ...................................................... the provisions of TIT?• 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board offhealth. Signe��.1...-—_-.))al A;.,'i't i.2/.... !. .... ... .. .. -d --.._ Date Application Approved By.. -a ✓�i ��-��— _ l................ � � i«--r ..-• --•-- Da te Application Disapproved for the following reasons:............................................................................................................«« ..-•-•......................................••--••--•---•--...--•--•-•--------........----......-----••--••--............----...._..--•---.-••-•-----..............•--••-............................... Date Permit No...... ......I # E •---•--•-•..................«.. Issued....------•---- .......-------•---..........-•---- Date ------------- THE r COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTHtr Tn.......... .......... .. ......................................... tif irate of (fautpliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) G PCM1P1 Installer at............... .-s........---•--. ..... =..--•-----•---...----•-----•-------•-------........-------••------..................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.� �....?.«� ............ dated. -:�Lt:16 5.................. r ° THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL.FUNCTION SATISFACTORY. DATE.............•. ..... , ............................................. Inspector....................................----......-----.......-----..................... THE COMMONWEALTH OF MASSACHUSETTS I �1 n BOARD OF HEALTH f�_,t ...........L .W...K.................OF.. 1"i► ?T .... .�. ..� !. cj2_ No......................... � cl 1 Fn........................ disposal Workii Tonstrudiatt ratni Permission is hereby granted................... L- ✓'Y / •-•------•-------•................•---•.........•-•........... .............•------.:...... - to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.....................................J......6...'. = ` '. ?............................•----•••-••.................•-...............•--.......---••••--•.................. Street �ll�DQ' as shown on the application for Disposal Works Construction Permit No......................Dated...!....._..]. ............... ....... ...............•--------........._.......---------------•---- ................................ 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