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HomeMy WebLinkAbout0070 MAPLE STREET - Health (2) ro N 6 N CD cn eve_. �f.P fi_ i '✓� ^ `)"AA 0 � ��� �� ����� �o � � ���� �������� -�' � � ��� �� ����`��,T �� ������ � ����� r rd „ - - e- �, FS• 3 f F A t x � � s Y � L . 9 , � a - • e f�x �.r y } T � JE. V. , e JL im 14, Ini el Is 19 e q .. .. • i7 �x r r g ~ •3 J -07 All . t � 440 N CD •. fat . � ;jf €.` '`p n * . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 70 Maple st r Property Address Pascal and Elise Nicolle . Owner Owner's Name ~ information is � required for every W Barnstable Ma 02668 12/14/15 a page. Cityrrown State Zip Code Date of Inspection GW W Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, -3 09 use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Q Company Name 8 Johns path Company Address S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluati y the Local Approving Authority 12/16/15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal •System Page 1 of 17 Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Maple st Property Address k Pascal and Elise Nicolle Owner Owner's Name inforrpation is reg uir``ed for every W Barnstable Ma 02668 12/14/15 page..., Cityrrown State Zip Code Date of Inspection T; B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels 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 tank septic p to will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments °M 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. Citylfown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is.less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I I i D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System•Page 4 of 17 is Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurf ace Sewage Disposal System•Page 5 of 17 C ' ommonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y rY 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 � page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recent) or as art of ❑ ® 9 Y Y p this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of.break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage 219 Gpd 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2011 Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 70 Maple st M Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 25 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 40" 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.): .System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: 3.5 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. CityrTown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments LAM 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. 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.): I Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At normal level 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.): Distribution Box is level and at normal level with no signs of carry over or decay. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology.- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of carry over and no signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydraulic failure. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r �. Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ftfeet 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: 11/8/89 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: Test hole data on plan dated 11/8/89 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 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 i i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts 132? Title 5 Official Inspection Form " Subsurface Sewage`Disposal System Form -Not for Voluntary Assessments K, 70 Maple st - Property Address ?r::• ->r. =: I;r„r; p � Pascal'rand'Elise'Nicolle ' Owner _ Owner's Name information is, - - required for every .W Barristable', ✓ Ma 02668 12/14115, page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any 4" way. Please see coinpleteness checklist at the end of the form. Important:When A. General Information filling out forms C/ 11399 on the computer, Jl use only the tab 1. Inspector: key to move your cursor-do not ____ Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain ; reb Company Name 8 Johns path Company Address r.; rr S Yarmouth - MA • ,.02664 City/Town State Zip Code 508=364=9587 S113522 Telephone Number License Number B. Cerf'ification' s_�: , ; :: j=.G I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes` ❑ Fails ❑ Needs Further Evaluation byMhe Local Approving Authority i 12/16/15 I pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If,the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 r. Commonwealth of Massachusetts W Title 5 Official lns � j - ;;rt�, pecti�on., �'orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y,e ' `�M - •'— ---70=-Maple-st._ _ Property Address — ------ ----Pascal and Elise-Nicolle Owner Owner's Name information is `t --required for every,,. W Barnstable Ma 02668 12/14/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A)� System Passes: ® I have not,found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1000 gallon tank as well as a concrefe Distribution box. All tees and baffle are in place. The Distribution box is level and at normal level. Thes leaching . . leachin cham g Is made up of several bers and at time_ �f inspection levels'appeared to never have been at abnormal levels 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 structural) unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass y 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): 4r li (l.ni ' it lilt�'+ ti/1':I I}.a i,`l'l\'Sil. ....� �1r r, 4v:�M1r'I .1 .ie.17�S1.1 L:.A..t)f' ?kt•r� r•yk yy i' h t5ins-3/13- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official : Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. ,. wM 70 Maple st Property Address - Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15• . page. City/7own State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of-Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout 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): K C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. - 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is-not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ., �-.,..j.,�, •.i '.'�jig� ... ,... . °mow Commonwealth of Massachusetts ■. �. Title 5 Offidal Inspectio n F0 rm u a c'Jt� rr1 ,.�� Subsurfacen"Sewage Disposal System Form -Not'for Voluntary Assessments Property Address _.-Pascal and Elise-Nicolle- ` Owner Owner's Name information is 'r.i.,,rvc•I required for every W Barnstable :, Ma 02668 12/14/15 - page. City/Town _ _. State Zip Code Date of Inspection B. Certification (cost.) 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: ❑-.T,he-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. _I ❑ 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: bu, **3This system passes if the well water analysis.,,performed at a DEP certified laboratory, for fecal ,l„ ;;- r 'Tcoliform bacteria,indicates absent and the presenceof:!ammonia nitrogen and nitrate nitrogen is equal to°or less than 5`ppmprovided that no other failure criteria are triggered. A copy of the analysis must be:attached.ta:thisnform. ' 3: Other: :, i D) System Failure Criteria Applicable to All Systems: t You must in'dticate "Yes" or"No"to each of the following for all-inspections: i t` Il' r71;r V lb. Yes No Backup of sewage into facility o`r system component due to overloaded or clogged SAS or cesspool ' Discharge or ponding of effluent:to the surface.of the.ground or surface waters ' due to an overloaded or clogged SAS or cesspool,, . Static liquid level in the distribution,box above outlet invert due to an overloaded or clogged SAS or cesspool; ❑ ® Liquid depth in cesspool is"less th'an.W below invert'or available volume is less than '/2 day flow t5ins•3/13`- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form -_ Subsurface Sewage Disposal System Form - Not for Voluntary-Assessments w 70 Maple"st Property Address Pascal and Elise Nicolle Owner . Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or .- obstructed pipe(s). Number of times pumped: ❑: .s `', Any"portion'of the"SAS;cesspool or`privy is'belov✓high groundwater elevation. ® Any portion of cesspool or privy is within 100 feet cf 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•"indicatesabsent and the presence ; «: , of ammonia nitrogen and nitrate nitrogen is;equ.al: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.] 0 ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® 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 ❑:i.`t may'.❑�'C." ;,;_! ..,- �a - ' � 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.' _ l5ins•3/13 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. u.�. Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments £. 4 -70-Maple-st Property Address --Pascal-and Elise-Nicolle _ f Owner Owner's Name information is W Barnstable required for every Ma 02668; 12/14/15 page. City/Town State Zip Code Date of Inspection C. Checklist a i i ! Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes Not. ❑ ® 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? 1 . 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 Y sewage disposal systems? p 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: `,�lV ll't i65 ii;J 1UG ('1 '(<';, } U i Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments M 70 Maple st ' Property Address Pascal and Elise Nicolle Owner Owner's Name information is W Barnstable Ma 02668 12/14/15 required for every - page. City/Town' State Zip Code Date of Inspection D. System Information Description: . The system contains a 1000 gallon tank as well as a concrete.Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) <i Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter,readings, if available last 2 ears usage 219 Gpd _ r 9 r ( Y 9 (gPd))� � . Detail Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: . Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank present? ❑ Yes El No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts , W Title 5 Official Ins ection 'Form r Subsurfakll wage Disposal System Form -Not for Voluntary Assessmentsi. �r ? t ttr , Property Address Pascal-and Elise Nicolle ., Owner Owner's Name information is required for every W Barnstable Ma 02668 - 12/14/15 page _ .... CitYrrown - - - -- - State Zip Code, --,Date of Inspection D. System Information (cont) Last-date of occupancy/use: pate Other(describe below): _- ' - _ + .. ....�t;x=i1•ciS- ter., 9 ai+. .. General Information Pumping Records: ' _;V ;'.:, .',Source,of information: ,1- ,-1.,.�i'I Was system pumped as part of the inspection? f, r ❑, -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 ! '''39'inspection of the I/A system by system operator under contract �i.,'i' ;03 i} `•f ., •�w ; ✓�,�.;i,l , 'ram.r, lr..� `'17i '!S�"�t.. f,.•..� ,:+ - ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): o.. ; t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection F.orrn l , Subsurface Sewage Dis+posal System Form - Not for Voluntary Assessments�.W • =tt , 70 Maple st t J ,• Property Address Pascal and Elise Nicolle Owner Owner's Name information is W Barnstable Ma 02668 12/14/15 required for every ' • page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 25 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): _ - Depth below grade: 40„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.): system is vented throught the roof. T l Septic Tank (locate on site plan): Depth below grade: 3.5 It feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene , ❑ other(explain) 1000 gallon u r.]f tank is'metal, Iist age:,•,,-d,: i ::i:ii)�:r:'.:,is., `iJ •..,...:17 ii iii'' •_' .,.. ' ;!year$ Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) _ ❑ Yes ❑ No Dimensions: Sludge depth: (Sins•3113 Title 5 Official Inspection Form:Snub urfa:..a Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Ins ectioftf6rm ;t o-. Subsurface Sewage Disposal System Form - Not for V oluntary Assessments -—70-Maple-st----' - —-- -- - - - - - -- ' - - / 1 Property Address --- — Pascal-and-EIise-Nicolle- Owner Owner's Name information is required for every,(;: W Barnstable - Ma -`02668` - 12/14/15 .; page. --- Cltylrown - -- 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 24 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 1" Sludge stick How were dimensions determined? t' Tape Measure - Comments (on pumping recommendations, inlet and outlet tee'or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Traplocate on site plan): ( P ) :: NA .. Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 4 Dimensions: . Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17- Commonwealth of Massachusetts Title 5 Official ] nspection Fora . Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments ..!,at•!„� .,.. `.-�'.�.'4,.i . _ .i. - ... •t..t e. '•l:1,-.. : ,� .1Jt_.-1t x. :� 4.: -_ . 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is W Barnstable required for every Ma 02668 .12/14/15 page. CityrFown 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.): Tees are in place and levels are normal. Tight or,H,olding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material;of,construction: ❑ concrete ❑ metal ❑ fiberglass ❑ of eth lene El- --- -- _ -- -- - - --- ------ .P y -y_-_ -- other(explain): Dimensions: Capacity: gallons , Design Flow: gallons per day Alarm present: ❑ Yes r ❑ No Alarm level: Alarm in working order: '(es ❑ No Date of last pumping: Date,,, I Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts , 55 Y Title 5 lOfficbial Inspection .Form � �r _ a Subsurface`Sewage Disposal System Form - Not for Voluntary Assessments a q. 4Y --- -70 Maple_st .-..- Property Address - — — Pascal-and-Elise-Nicolle Owner Owher'S Name, r ; information is y ' required for every ] W Barnstable. Ma 02668 12/14/'15 u r _ page, _. ... _ .._-Cltylrown - _ __.._._._. ., - State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site,plan): At normal level Depth of liquid level above outlet invert ^ - w - --� - Comments (notelif'box.is level and distribution to outlets-equal,'ar,'y eviderce:of solids carryover, any evidence of leakage into or out of box, etc.): -- Distribution Boz�is-level and at normal level with no signs of barry'over or decay. _ �,." ' J Pump Chamber(locate on site plan): ,, (i Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc,): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary. Assessments M 70 Maple st ` Property Address 9,.•:,. ... Pascal and Elise Nicolle Owner Owner's Name information is every -W Barnstable " required for eve Ma 02668 12/14/15 page. Cityrrown, State ZipCode bateDate of Inspection D. System-Information (cont.) Type: ❑ leaching pits number:. ❑ " leaching chambers : number...? I.— t f _ ® leaching galleries number:,,_ ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure; level of ponding, damp soil, condition of. vegetation, etc.): No signs of car over and no signs of hydraulic failure Cesspools (cesspool must be'pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer a�,-:;,,.:•.1r :., ,e;;1i,-._,:'� ,i i„1., . . ass '.. ... Depth of scum layer - Dimensions of cesspool _ Materials of construction Indication of groundwater inflow El Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subs rFace Sewage Disposal System•Page 13 of 17 .*raw"� �e•�,�`> Fyn` ic��,� �r}•F. . ' Commonwealth of Massachusetts W Title. 5 Official Inspection , Form i... �, +r.-..�..5, -.'.P..� -a)Ci .:� 3y. "I:" Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -.---- ,70 Maple st—_ Property Address s r -- Pascal and-Elise-Nicolle-- Owner Owner's Name, information is +: W-Barnstable - - Ma - 02668 12/14/15 . required-for every ;, � �'�-• �• page. --Clty/rown - ---- - --- State — Zip Code Date of Inspection D. System Information (cont.) ,,CommentsI(note condition of soil, signs of hydraulic failure, level of ponding,.condition of vegetation, etc.) •.,_, . , ,L�,,- � • No signs of ponding or hydraulic failure. Privy (locate on site plan): Materials of construction: , Dimensions i i Depth of solids Comments (note condition of soil, signs of hydraulic failure,!,level of ponding,,condition of vegetation, etc.): l i i I i 1 j t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts le 5 Official Inspection Form - Subsurface Sewage Disposal"System Form -Not for Voluntary Assessments �M 70 Maple st Property Address _ , Pascal and Elise Nicolle `` " ' "....' Owner Owner's Name information is „r : required for every W Barnstable Ma 02668 12/14/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at'least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately _T,-D. LJ - I ------------------------------- 0 D G t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title. 5 Official Inspection-Fora,`,*,- J. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments-, {, J _ ,.j ;iii ---70 Maple Property Address - - --- - - n: --- -----Pascal-and Elise Nicolle Owner Owner's Name information is required for every W Barnstable' Ma - 02668 12/14/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Surface wafter ❑ Check cellar ❑ Shallow wells, Estimated depth to high ground water: 10+ ft L i 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 11/8/89 ' ❑ Observed site (abutting property/o,bservati,on„hole,within 1,50 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: Test hole data on plan dated 11/8/89 Before filing this„Inspection Report, please see Report Completeness Checklist on next page' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of(Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Noffor Voluntary! , : .. . _ ... .. . . .. ntary Assessments '� Y • - `�M ,•• 70 Maple st r ,ilF r,:i, , :i ; •:, , .' ... ... �_ _c.,, Property Address f-+ Pascal and Elise NicolleOwner - information is ot^'ner's Name required for every W Barnstable page. City/Town Ma..,. 02668, 12/14/15 State Zip Code Date.of Inspection D. System Information (cont.) Site Exam: ® Check Slope - ® Surface water 4 ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate,all,methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date o' f design plan reviewed: 11/8/89 .. t Date ❑"- Observed;site (abutfing property/observation hole within 150 feet of SAS) { '❑ ' '• Checked'wifh'loc'al of Board , _ Health `explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan dated 11/8/89 Before filing this Inspection Report,.please see Report Completeness Checklist on next page. 15ins-3113 f` r• ` - Title 5 official Inspection Form:'Subsurface Sewage Disposal System-Page 16 of 17 w` Commonwealth of Massachusetts Title 5 Official Inspection Fora 9 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 70 Maple st Property Address Pascal and Elise Nicolle Owner Owner's Name information is required for every W Barnstable Ma 02668 12/14/15 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 i l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 J COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENvi ri ONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P In '^� S•`� MAY 1 0 2005 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: x) r Owner's.Name: Owner's Address:9n. Date of Inspection: —1 7 Name of Inspect lea print Company Name. Mailing Address: C.���11 �_ Telephone Number: Y CERTIFICATION STATEMENT / I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the-inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant'to Section 15.340 of Title 5(310 CMR 15.000). The system: t9 Passes Conditionally Passes . Needs Further Evaluation by the Local Approving Authority f'a ]s Inspector's Signature: Date: Q 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 reportto the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in.the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 y Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ;/ - 4M -- F Owner: ,.A Date of. f nspection: Inspection.Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. S stem Passes: I have not found anyinfonnation which indicates that any of the failure criieria described in 3 10 CMR 15303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments. B; System Conditionally Passes:. One or more system componentz 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. Answer yes,no or not determined(Y,KND)in the for the following statements. If"not.determined"please explain: The septic tank is metal and ove€20 years old* or the septic tank.(wheiher 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 inspectiom if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y--ars old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution.box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with.. approval of Board of Health):, broken pipe(s)are replaced obstruction is removed distribution box.is leveled or replaced ND explain: 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):. brok--n pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1'1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continu-1d) Property Address: '6 - Owner: _ Date of Inspection: 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«-etland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any determines that the system is functioning in a.manner that protects the public health,safety and environment: _ 'The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within z Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system-has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to cr 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: 3 Page 4 of I I OFFICI'AL.INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: l2e a&,_ Owner- ?U.t "r7�`(�1i.�LoC Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to eacp of the following for all inspections: Yes Iv' _ F Backup sewage ogg / p of se abe into facility or.system component due to overloaded or clo,�ed:SAS or cesspool. Q Dischar e v _ � or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution.box.above outlet invert due to an overloaded.or clogged SAS or cesspool Liquid depth in.cesspool is less than 6"below invert or available volume is less than %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 groundwater elevation. _ Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface f .water supply. Any portion of a cesspool oz-privy is within a Zone I of a public well. Any portion of a cesspool o privy is within 50 feet of a private water supply well. Any portion of a cesspool cr--privy is less than 100 feet but greater than.50 feet from a private water supply well-with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a.DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen-and nitrate nitrcgen.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.] A(Yes/No)The system fails. I h ve 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 v`:ill be necessary to correct the failure. E. Large Systems: To be considered a.large system the system.must serve a facility with a'design flow of 10,000:gpd to.15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The.following criteria apply to large systems in addition to the criteria above) yes no the.system is within 400 feet of a surface drinking water supply the system is within 200 feet.of a tributary to a surface drinking water supply —the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area.—IWPA)or a mapped Zone IL 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. I 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST P-7) d_x,06p, Property Address: /U Owner: c.oG Date of Inspection: Check if the following have been done. You must indicate"yes"or"no" a_to each of the following: _ Yes No • I Pumping.;nformatio.n..was provided by the owner,occupant, or Board of Health Z'Were. any of the system components pumped out in the previous two weeks as the system received normal flows in the previous two weed 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 tl-iey were not available note as N/A) Was the facility.or dwelling inspected for signs of sewage backup V Was the site inspected for signs of breakout? Were all system components,excluding the SAS, located on s_te 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: depot of sludge and depth of scum? 'Was.the facility owner(and occupants if different froth owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on_he site has been determined based on: Yes 'no' — Existing information. For example,a plan.at the Board of Heal h. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 1 I OFFICIAL INSYECTIONTORM-NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE, DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION Property Address: 14 ,2 Owner:./�C Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):2. Number of:bedrooms(actual): DESIGN flow basedon 310 CMR 15203 for Q �( exam e•pl . 110 bpd x#of bedrooms): 36 Number of current residentse G� / Does residence have.a garbage grin (yes or no): /U Is laundry on a separate sewage system (yes or no);,( .[if yes separate inspection required] Laundry system inspected (y s or no);16 Seasonal use: (yes or nQ)IV Water meter readings, if av 'lable(last 2 years usage(gpd)): Sump pump(yes or no):/Yd nn,,�p Last date of occupancy: 4L ' COMMERCIAL/INDUSTRIAL Type of establishment:. Design flow(based on 310 CMR.15._03): gpd Basis of design.flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present ryes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available:- Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the ens-Dection(yes or no): , If yes, volume pumped: gallons--How was quantity pumped determined? Reason Tor.pumping: T OF SYSTEM Septic tank, distribution box,soil abso Lion system � I Single cesspool _Overflow cesspool Privy _Shared system.(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP.approval —Other(describe): Appr xima e age of all components, date stalle if kno n)and source of information. Were sewage odors detected when arr ving.at the site(yes or no :_0 Page 7 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 17 Property Address: —z /A `11(4A Owner: <- M Date of Inspection: �— BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain):- Distance from private water supply well or suction line: Comments (on condition of joints, venting,evidence of leakage, etc.): ' SEPTIC TANK: 1XIlocate own site ©plan) Depth below grade:�� Material of construction:__L;�ebncrete_metal_fiberglass_polyethylene _othef(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) + Dimensions: Sludge depth: Distance from top off sludge to bottom of outlet tee of baffle: Scum thickness: l ,1 Distance from top of scum to top of outlet tee or baffle: '✓• Distance from bottom of scum to bottom of outlet teq or baffle: /3 How were dimensions determined: h �, Comments(on pumping recommen atio�and outlet tee or baffle condition, structural integrity,liquid levels i­hs related to outlet invert,,evidence of leakage,etc.): J.i 1Cx� GREASE TRAY locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Page 8 of I I OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS` > SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property.Address: L � Owner:. X --,*A-Q Date of Inspection: TIGHT or HOLDING TAN1 (ink 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: gallor_s Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,.etc.); DISTRIBUTION • ZifBOX. present_must be opened)(locate on site plan) Depth of liquid level above outlet�inver8 Comments (note if box is level and distrbution.to.outle (equal,any evidence of solids carryover, any evidence of. r-1, akage into ir out of bo c.): PUMP CHAMBE (locate on s-e plan) Pumps in working order(yes or no). Alarms in working order(yes or no): Comments (note.condition of pump chamber, condition of pumps and appurtenances,etc.): . 8 I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ( MCI e'u- uel Ah " , Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leac,hing chambers,number aching galleries,number: _leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool; number: innovative/alternative system Type/name of technology; Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp.soi% condition of vegetation. V r( CESSPOOLS;/(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):" PRIVY�(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 1.0 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property.Address:. Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL,.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Loc.a-te..where public water supply enters the building. l ® p O 10 Page l l of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) .Property Address: _ Owner: 1 Date of Inspection• ' � SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water /� feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: I 11 Permit Number: Date:. Completed by: ! HIGH GROUND-WATER LEVEL COMPUTATION i Site Location: 7v 6/ - Kon 45�100V Lot No. Owner: /0 / (J �'!� /`v Address: , Contractor: /1� � c5r Address: Z61el". !. Notes: �5&h //S i STEP 1 Measure depth to waver table i .to nearest 1/10 ft. .................................. ....................... .Date 1 month/day/year i STEP! 2 Using Water-Level Range Zone i and Index Well Map locate I site and determine: 4 .... ZJ`� OA Appropriate index well............................... OB Water-level range zone ..................................................... STEP 3 Using monthly report"Current Water Resources.Conditions" determine current depth to z ! ✓��� �i i water level for index well ........................... month/year STEP! 4 Using Table of Water-evel Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), Y: jand water-level zone (STEP 213) j determine water-level adjustment .........................:................................................. ........... STEP; 5 Estimate depth to high water K; by subtracting the water- level adjustment (STEP 4) ! from measured depth to water levelat site (STEP 1) ......................................................:...... f�i ............ : ..< �� �[ 4 ' y C Figure 13.--Reproducible computation form. r r 1 x 15 • :Y i 4 i 111 :f-7•>r:1i�) i _... tIl.; i i I �� I "Bottle- Number:-` -MAS * 1'79 Date: 02/18/94 BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE V BARNSTABLE, MASSACHUSETTS 02630 AlA 5 ej PHONE: 362-2511 Client: CHAMPION BUILDERS Collector: MEEHAM WELL DRII�AeING Mailing P O BOX 1558 Affiliation: OTHER Address: BUZZARDS BAY MA 02532 Type of Supply: Telephone: 888-5458 Well Depth: Sample Location: MAPLE ST LOT #2 Date of Collection: 02/17/94 Town: WEST BARNSTABLE Date of Analysis: 02/18/94 ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- - PARAMETER SAMPLE RESULT RECOMMENDED LIMITS ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Total Coliform Bacteria/100mL 0 0 pH Conductivity (micromhos/cm) 500 Iron (ppm) 0.3 Nitrate-Nitrogen (ppm) 10.0 Sodium (ppm) 20.0 Copper (ppm) 1.3 - -------------------------------------------------------------- BASED ON THE ANALYSES PERFORMED, THE FOLLOWING ADVISORIES ARE GIVEN: This is a Retest. * Water sample meets the recommended limits for drinking water of all above tested parameters. Thomas F. Bourne, Laboratory Director CERTIFICATE OF ANALYSIS Page. 1 Barnstable County Health Laboratory -- Report Dated: 11/18/2005 Report Prepared For: Order No.: G0533763 Charles Harden P O Box 990 . Barnstable, MA 02630 Laboratory ID#: 0533763-01 Description: Water-Drinking Water Sample#: 33763 Sampling Location CIO MaplcSt:W'[3a'rnstabte;MA---: Collected: 11/16/2005 Collected by: C.Harden Map 132 Parcel 021/002 Received: 11/16/2005 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen BRL mg/L 0.10 10 EPA 300.0 11/16/2005 LAB: Metals Copper BRL mg/L 0.10 1.3 SM 311113 11/18/2005 Iron BRL mg/L 0.10 0.3 SM 311113 11/18/2005 Sodium 7.1 mg/L 1.0 20 SM 311113 11/18/2005 LAB: Microbiology i Total Coliform Absent P/A 0 0 309 11/16/2005 LAB: Physical Chemistry Conductance 110 umohs/cm 1.0 EPA 120.1 11/16/2005 pH 7,1 pH-units 0 EPA 150.1 11/16/2005 Water sample meets the recommended-limits for drinking water of all theabove tested parameters. Approved By: (L hector) J RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 L BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS Client: CHAMPION BUILDERS INC Collection Date: 02/07/94 Mailing Address :P 0 BOX 1558 Date of Analysis :02/11/94 BUZZARDS BAY MA 02532 Type of Supply: WELL Well Depth (FT) : 35 Telephone : Sample Location:LOT 2 MAPLE STREET LAT. (DDMMSS) : Not Given BARNSTABLE LONG. (DDMMSS) : Not Given Collector : C STIEFEL Map/Parcel : Affiliation: BCHD Analytical Method: 502. 1=1 , 502 . 2=2 , 503 . 1=3 , 504=4 , 524 . 1=5 , 524 . 2=6 , 502 . 1/503=7 Contaminants Anal . Result MCL Detection Detected Meth. ug/1 ug/1 Limits (ug/1) --------------------------------------------------------------------- *** NO COMPOUNDS DETECTED *** 2 Only those compounds listed above were detected. Attached is a list of compounds for which this sample was analyzed. NOTE: Contaminant levels equal to or exceeding the Detection Limits are reported. MCL means Maximum Contaminant Level for EPA-regulated compounds . (ug/l = micrograms per liter = Parts Per Billion) The Environmental Protection Agency has set Maximum Contaminant Levels (MCL) for the following compounds . This sample compares as follows : COMPOUND MCL (in PPB) Benzene 5. 0 * level not exceeded * Carbon Tetrachloride 5. 0 * level not exceeded * 1 , 2-Dichloroethane 5. 0 * level not exceeded * 1 , 1-Dichloroethene 7 .0 * level not exceeded * 1 , 4-Dichlorobenzene 75 * level not exceeded * 1 , 1 , 1-Trichloroethane 200 * level not exceeded * Trichloroethene 5. 0 * level not exceeded * Vinyl Chloride 2 . 0 * level not exceeded * Comments or additional compounds found: 4 '= �9 Thomas F. Bourne , Laboratory Director �' �v�v i/�r•a,cQ I . — 0A, �. #­ - .1 �3 1 , a P. [ - No.. :l �d Flca........ ..... O JTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE q.5 ' Appliration for Dig opal lVorkii Tantitrnrtion runfit Application is hereby made for a Permit to Construct A or Repair ( ) an Individual Sewage Disposal Systemat: ...........--................................................. C ' ..........................i. W am... Location- \ddrrss r LoL 1 ---- ............................... Cinl Add ss � Installer Address U Type of Building Size Lot... .....Sq. feet t-, Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------------------------------------•-------._....---- ------...------....---•-•---•--------••--••----••--•••.••--•- W Design Flow.................55.._...._. _....__-_gallons per person per day. Total daily flow...._._......_ g g� P P P Y Y �-2�--�...................gallons. WSeptic Tank—Liquid capaci----- 4i.gallons Length__-- �`o_�_ Width.t�l o_" Diameter--------------- Depth...�g.Y x Disposal Trench--No.+-e!r.:!?tFF..•Width..0:'_€-fit_... Total Length...... o -`rr Total leaching area.. 3._ q ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b J.0....... t ___P '--•- Date.......... ,aa Test Pit No. 1...` __minutes per inch Depth of Test Pit----�.' .*` '... Depth to ground water.._._...1`!Ot....... fi, Test Pit No. 2..k.........minutes per inch Depth of Test Pit---L5.1......... Depth to ground water........!-41/A�._-_.- 9 •---•---•.......................•--•••-•••-•--......._....-•-•-----.......-•-•--•----------•-•..-•---............-•------•---............................. .. O Description of Soil_'C�!.s�....-°:! •:-! `� -5 t13--_._.... "y(0'_L'-:_`�--o__s�,uo, .................................` �.:... `f 1 �inS._.Se.wE✓J .�._0-30"... 3..... 1L...M vJR..SA+{! ...'fn :�:......iL!......1Z---.© : .....1 . . ►..t.��: 5a.•r.....,:.'rts.u. . ........,.. UNature of Repairs or Alterations—Answer when applicable............................................................................................... •--------------------------------------------------------•-•-----------•----------------•---•----••.----------------------..._..------------....--------------------------------------------•--••--..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the sue system in operation until a Certificate of Compliance has en by the rd df th. .....j5�1 Y""14 ..... Signed ---------- ...................... .... j ......................... Application Approved By ............. ._' .,t..,K,,,,, - _e:...l.. . Application Disapproved for the following reafonf: ............................................................................................................ ......................... .......................................................Q....................................................................................................................................................... ........................................ Permit No. ........../....y........g.0..... .................. Issued D ............................. Date �,.,w,�...y..+-�+ .r a. ..n-.r.� '.-..^r✓ �:....�. v .. -Vcr-�.:...v •e,ti.s-.,-Y,...�,r.o..y .,,;.. r;wr v.r .vr... �:.rv'..�,.� ,_..__. � ..... _Fa- ,.�_.._ .V e���._- 4. No.. .4-:_.3® ` - 0 �� FEB d ..... " THE COMMONWEALTH OF MASSACHUSETTS b�qL� BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di►ipwml Worko Togtotriarfion Permit Application is hereby made for a Permit to Construct (-,-) or Repair ( ) an Individual Sewage Disposal System at: Location-Address t or Lot No. ......................_......................................................................... .............--a'- /'Z Z-:-/ ................................... O,en Address ........�.j Installer Address Type of Building Size Lot...�a:. .....Sq. feet ., Dwelling— No. of Bedrooms------------______--------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria a' Other fixtures _______________________________ _ _ W Design Flow.................5>!- .....................gallons per person per day. Total daily flow............ ..........._.....__gallons. WSeptic Tank—Liquid capacity C24?�?_gallons Length---- Width__ _a.o._ Diameter................ D.�—e�p-��th............'. x Disposal Trench--No. _.... ....'FF.Width._��:.'.. .... ... Total Length_.___?_ �% Total leaching area.. %_`f`fsq ft. 3 Seepage Pit No--------._---_____- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by._.......�:-_._._ ._Z._'_c ..-..... )�..___... Date.............................II " t5t� a ........_.. Test Pit No. I--- _.' .....minutes per inch Depth of Test Pit.... -?_!,..__.. Depth to ground water........."/..a........ Lz. Test Pit No. 2.. '...y.._._minutes per inch Depth of Test Pit... ...... Depth to ground water........t._/A ._... P+ ---•--------------------•---••--•--••----•-•-••------••---•••--•••------.............-------___..............••-----.........••---•----......._•-•----•--•--- D Description of Soil.?.N_Q_ D, "'f : t L S�t;3 2 4- ,1&_.. L- ~4 t�, Sd .�: '1,7^c_e, 5� r•--..._............`1 U � -t1-, S�-t,11 �� o '�O` To sit 3 - -5-`1- -) i,..� ...... LA t .. 1 .. . SA. e.� �riLFc4 2 t__ �_. VNature of Repairs or Alterations—Answer when applicable...__._......................................................................................... ................................................=....................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has.been issued by.tthhee b and of�heeaaltthh Signed .............W .� ....... .._ ...... Date Application Approved BY ------ -----�4n...��. � . t ......... ................................................................. . �i..- ...-..L..(-./ Date Application Disapproved for the following reasons: ....... ... ... ..... . ............................................... .................................. .......................................................g........................................ ............................................................ . ... -- --........... --........ .................................... Permit No. ........../... R Date .......................... Issued ...... Dace b�---. �..-- — ter------. ---.--_--__f,_ —.— —.___ ...__. —___, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE T Ter#tftctt#e of Tontlifiance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ------------------ �z� C .. tt,.rta ne. . ......... _.... ........................... . .............. ............. ....... at . - - .... .. . ...............c-:�`.. 1 ...,........ - ( Qr�.................. has been installed in accordance IvJ'ce provisions of TITLE 5 o The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...-....7.�..-..-Fe).......... dated ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. i - Cf .. - _... Inspector -�.... - - DATE...........__..............�1...._ ....._�..............f.... 1 i, -- _- _----------------------- __:-_---------- --_------__- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �7 TOWN OF BARNSTABLE O No.....-..�-_...,..--- ` FEE.. ..... �io�roottl or�o �,,oa�o�rirrn �rrntit Permission is hereby granted � ,►> ............... to Construct (u) or Repair ( ) an Individual Sewage Disposal System atNo........G'-=••en--7------- ......... : Q,?.........�T-:-------.....I`'.J-,......1� � 7--------------------"-'•.........--•-- -" Str,:et 7y Ka as shown on the-a application for Disposal ��'torls Construction Permit No___ ____ __________ Datedl�_.__...._......_.__�1.n........_...... PP P ------------- A � ----- Board of Health DATE............................ ,� ......... FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS ti rt 9 flv � V L� , all, # s t Q • r 1 ► I i '• •' Im i i I ► • •' ► • III 1 • •' • ► 111 waRUM► I i '• i I I • 1 1 SI I ► , , COVER SHEET & INDEX i • f • ;. frorem FLOOR PLANS ►• �� ® NEE + V ALL MARKED POSTS TO HAVE mroTly ►. Ive- • -= SIMPSON 5THD&HOLD DOkNNS M nO= 3D OVERVIEWS y I// • • • •1 CAR • I' GARAOE PLAN03, • • ►� ,t f • ►S • f ►I Ii ►. ,. MEN SEE ■ !g ;. 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I 3/4/16 (L 11/5/15 I ( DRA NN B) C) Jim SHEET # m , ut 3 24' O0—a- - 0 4 x 6 WINDOW/DOOR FRAMES k. 4 x 4 CROSS BRACING MCI I� b x b TOP PLATE Da Da Da DO D R TIMBER PANEL b x b P05TS 4 x 4 TYP. 6 x 6 FULL HEIGHT CORNER POSTS Lu tL Q TIMBER PANEL IF W QWC uA Z Z JU Z to tu C r 1! I REAR N ALL DETAIL RIGHT NArLL DETAIL w ua A S l IT x 11W TOP PLATE ` J TP PLATE 2.4(TIMBER PANEL) J �.A 112-x1"IAO SCREW94"MINIMUM EMBEDMENT N51'4 2 x 4(TIMBER PANEL) 1 It} e'r* ;i/"6 `�- DATE: PANEL IDfH a1 V 4 x4 PURLJNS .I-'•?• �'�6y$il?.., `5-1, ' PANEL 5 SH kLL U1 3/4/16 B LE T N 1 t x 1z BIDING 4x 4 CORNER BRACES-ALL CORNERS DRI IN EP ANC RS 125"x 12T CORNER P05T 3} IR-!.rtpr'MS D RA4^4N B ZPT M ILLS /•.� LSTHOH STRAP J.M - _ _'�.,,.�. �••��'�,�.^v ��•�� ,_",,, _� �. 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EL. 28.0' '` AREA (V/F #1 I --J DECK \�� l i DECK I P P ; o I GRAVEL AREA ARAGE �--�� ON .SLAB \26 .� EL. 27.3 i PROP. WORK LIMIT INE OF ma`s 25 f' STAKED SILT FENCE MAP 132 PARCEL 21-1 •• VIM PEARL BRADSHAW 23 THICK VEGETATION 2 22 PROP. RE-LOCATED SHED SHED 20 \ 6t ZONING SUMMARY 18 ZONING DISTRICT: RF DISTRICT MIN. LOT SIZE 43,560 S.F. MIN. FRONT SETBACK 30' w MIN. SIDE SETBACK 15' #1 a F MIN. REAR SETBACK 15' #2 NOTES: 1. DATUM NAVD '88 2. WETLAND FLAGGED BY BRAD HALL 3. CONTRACTOR TO CONTACT DIG—SAFE PRIOR TO ANY CONSTRUCTION 4. DOWNSPOUTS TO BE DIRECTED TO DRYWELLS 5. REVEGETATE DISTURBED AREAS WITH FESCUES OWNER OF RECORD PASCAL & ELISA NICOLLE 3451 POINCIANA AVENUE MIAMI, FL 33133 REFERENCES DEED BOOK 20524 PAGE 5 SITE PLAN PLAN BOOK 424 PAGE 60 OF 70 MAPLE STREET WEST BARNSTABLE PREPARED FOR off 508-362-4541 ;y � ���. Ss} y M/M PASCAL NICOLLE fax 508-362-9880s �SIN '_ © �•° DAf- ELP DANIEL downcae.com � \ P �o 0"ALA A. m ?.. p r • � C:IL lit OJALA FEBRUARY 8, 2016 down ca a eag1nee lag, inc. 4 6502 A No.40980 civil engineers T4-� \tip �o`E ° �,.ztaM ' Scale: 1 20' land surveyors 939 Main Street ( Rte 6A) 0 10 20 30 40 50 FEET YARMOUTHPORT MA 02675 DATE DANIEL A. OJALA, P.E., P.L.S. 5-394