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Home My WebLink About2400 MEETINGHOUSE WAY/RTE 149 - Health (2) 2400 Meetinghouse Way West Barnstable A= 155-045 � r :ay 01, 2016 15:08 Jim The Inspector Man 5085349919. page 1 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments { a 2400 Meeting House Way m Property Address Ekaterina Morozova Owner Owner's Name information is required for every West Barnstable MA 02668 4-28-16 page. Cityrrown State Zip Code Date of Inspectio 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 ��vv�``�H OFrM z on the computer, "' /I �� \��......... `rS9c�� use only the tab 1. Inspector: �: •,yam. key to move your ' JAMES �' cursor-do not games D.SearS =p tr n use the return ke Name of Inspector Y• Capewide Enterprises, LLC Company Name N Sp�G 153 Commercial Street �''�►rnmm�nu��"``' 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 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r 4-28-16 nspector'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. A i 15ins•3113 Title 5 Official Irspedion Form:Subsulace Sewage Disposal System•Page 1 of 17 May 01, 2016 15:08 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Owner Owners Name information is West Barnstable MA 02668 4-28-16 required for every Rage_ 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: ® 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 six chambers. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Of tidal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 May 01 , 2016 15:08 Jim The Inspector. Man 5085349919 page 3 Commonwealth of Massachusetts 4.1 lag Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Owner Owner's Name information is West Barnstable MA 02668 4-28-16 required for every State Zip Code Date of Inspection page. City/Town B. Certification (cant.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Heafth 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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (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 ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (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 Tille 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 I May 01, 2016 15:08 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Owner owner's Name information is required for every West Barnstable MA 02668 4-28-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or El clogged SAS or cesspool El ® 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 El ® Liquid depth in is less than 6' below invert or available volume is less than '/2 day flow 1-&ACYIAI 15ins•all Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 May 01. 2016 15:08 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _2400 Meeting House Way Property Address Ekaterina Morozova Owner Owner's Name information is required for every West Barnstable MA 02668 4-28-16 page. Cityrfown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certrfied 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 forma ❑ ® 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 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D 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. 151ns•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 or 17 ,May 01, 2016 15:08 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Owner Owner's Name reformation is required for every West Barnstable MA 02668 4-28-16 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 NIA) ® ❑ 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): 6 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 6 of 17 ,May 01. 2016 15:08 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ra 2400 Meeting House Way Property Address Ekaterina Morozova Qwner Owner's Name information is required for every West Barnstable MA 02658 4.-28-16 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.Tank D Box and six chambers. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Well Water Detail: Owner to have Well Tested. Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sci.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsuface,Sewage Disposal System•Page 7 of 17 May 01, 2016 15:09 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Qwner Owner's Name information is required for every West Barnstable MA 02668 4-28-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use; Date Other(describe below): General Information Pumping Records: Source of information: NA 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): 15ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal system•Page 8 or 17 ,May 01. 2016 15:09 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekatehna Morozova Owner Owners Name information is West Barnstable MA 02668 4-28-16 required for every page. CityRown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2004 Permit#2004-454. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 23" 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.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): 13 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 Gala Precast H-10 Dimensions: 2e Sludge depth: t5ins•3113 - Title 5 Oftial Inspection Form:Subsurface Sewage Disposal system•Page 9 of 17 ,May 01. 2016 15:09 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 2400 Meeting House Way - - Property Address Ekatedna Morozova Owner Owner's Name information is West Barnstable MA 02668 4-28-16 required for every page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont,) Distance from top of sludge to bottom of outlet tee or baffle 28" Orr Scum thickness Bpi ,Distance from top of scum to top of outlet tee or baffle 'Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape- Plan 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 and inlet cover at 13" below grade w/out let cover at 4". In and out let tee's No sign of leakage or over loading Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 10 of 17 May 01. 2016 15:09 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekatenna Morozova Owner Owner's Name information is required for every West Barnstable MA 02668 4-28-16 page. Citylrown 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.): • i Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: i ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): i j i Dimensions: i Capacity: gallons i Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No. i Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I i i "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i i t i t5ins-3113 Title 5 Official Inspection Form:SubsLrface Sewage Disposal System•Page 11 of 17 i May 01. 2016 15:09 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Owner Owner's Name information is required for every West Barnstable MA 02668 4-28-16 page. CityrTown State Zip Code Date of inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16" -30" below grade w/two line's out. Box is clean and solid. No sign of over loading or solid carry 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: t5ins•3113 Title 5 Official Irspedion Form:Subsu.pface Sewage Disposal System•Page 12 of 17 ,May 01 2016 15:09 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts �3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r- 2400 Meeting House Way Property Address Ekaterina Morozova Owner Owner's Name information is West Barnstable MA 02668 4-28-16 . required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number. 6 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments'(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is six 500 Gal. Dry,Well Chambers. W/3'stone on sides 3.5' stone ends. Chambers are 40" below grade Chambers are dry. Wall's clean like new. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Officlal Inspection Form:Subsurface sewage Disposal System•Page 13 of 1T May 01 2016 15:10 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Owner Owner's Name information is West Barnstable MA 02668 4-28-16 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cons.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc. I Privy (locate on site plan): Materials of construction; Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5ins.3!13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 or 17 May 01 2016 15:10 Jim The Inspector Man 5085349919 page 15 k Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Owner Owners Name iequir dfo is West Barnstable MA 02668 4-28-16 required for every page. Clty/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 �ac5� REAR 13 �R o Roc K 2 tA A � t5ina•3113 - Title 5 Official Irspection Form:Subsurface Sewage Disposal System-Page 15 of 17 May 01 2016 15:10 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Owner Owner's Name information is West Barnstable MA 02668 4-28-16 required for every page CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No 11' Estimated depth high ground water: 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: 10-20-03 g p 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. o i Design Plan 10-20-03 no G.W. at 91'. Bottom of chamber's at 5'-10.below grade. Bottom of chamber's at 5'-2 above T.H. Depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title s official Inspection Form:Subsurface sewage Disposal system•Page 16 of 17 May 01 2016 15:10 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2400 Meeting House Way Property Address Ekaterina Morozova Owner Owner's Name Information is West Barnstable MA 02668 4-28-16 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Z Inspection Summary:A, B, C, D, or E checked 1Z Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3,113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of U i Commonwealth of Massachusetts ;F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2400 Meetinghouse Way M Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 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. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your ---i cursor-do not Ricky L. Wright key the return Name of Inspector Y B & B Excavation, Inc. r� Company Name 14 Teaberry Lane Company Address Forestdale MA e02644 City/Town State ,Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/21/10 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 V v Commonwealth of Massachusetts Oft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. ' A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 `i l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 q ed 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 l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 2400 iMeetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Citylrown 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow l5ins-09/08 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 °M 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 6 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments °M 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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-sanitarywaste discharged to the Title 5 system? Yes No 9 Y ❑ ❑ Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 1/2' feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: 30' feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good condition - no signs of leakage Septic Tank(locate on site plan): Depth below grade: 6"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: 5'8"X 5'8"X 10'6" Sludge depth: no sludge t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) e Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be in good condition - no signs of leakage Grease Tra p(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts ,RumW Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in very good condition -no signs of leakage or carryover Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 ❑ 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.): At time of inspection leaching is in good condition - no damp soils or ponding 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yr 2400 Meetinghouse Way Y Property Address Elizabth Wolsten Owner Owner's Name information is every West Barnstable re wired for eve MA 02668 6/21/10 page. Citylrown 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 4 3 c i 1 I' �k . 01 j h t51n5•Q9/t)8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 ffi O cial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope �k Surface water Check cellar Shallow wells Estimated depth to high ground water: 12'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: hand augered hole Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2400 Meetinghouse Way Property Address Elizabeth Wolsten Owner Owner's Name information is required for every West Barnstable MA 02668 6/21/10 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 V Commonwealth Of Massachusetts Executive Office Of Environmental Affairs Department Of Environmental Protection TITLE 5 Official Inspection Form -Not For Voluntary Assessments Subsurface Sewage Disposal System Form Part A Certification Property Address: 2400 Rt. 149 West Barnstable Ma.02668 c'D c� Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 \\ j 1 Name of Inspector(please print)Sean M.Jones#SI4522 Company Name: S.M.Jones Title V Septic Inspection Mailing Address: 74 Beldan Ln. Centerville Ma.02632 ��Z Telephone Number:508-778-4597 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 r approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: X Passes Conditionally Passes Needs further evaluation by the Local Approving Authority Fails Inspectors Signature Date: 7- The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time e ion and under the conditions of use at that time.This inspection does not address how �at W r-fornrin-the future under the same or different conditions of use. Page 1 6Z :C Wd I E 310 LOOZ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cowa-ium) Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.System Conditionally Passes:N/A One or more system components as described in the"Conditional Pass"section need to be replaced or Repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the_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 the 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 structurally sound,not leaking and if a Certificate of Compliance Indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or Obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with Approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced 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): broken pipe(s)are replaced obstruction is removed ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cONTMED) Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 C.Further Evaluation is required by the Board of Health:N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect public health,safety or the environment. 1.System will pass unless Board of health determines in accordance with 310CMR 15.303(1)(b)that the System functioning in a manner that protects the public health,safety and the environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a Surface water supplyor 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 less than 100 feet but 50 feet or more from a Private water supply well**.Method used to determine distance *#This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform Bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other Failure criteria are triggered.A copy of the analysis must be attached to this form. 3.Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(corrTmjm) Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of cesspool or privy is within Zone 1 of a public well. X Any portion of cesspool or privy is within 50 feet of a private water supply well. X Any portion of cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X (Yes/No)The system fails.I have determined that one or more of the above 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:N/A 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: 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 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 CM15.304.The system owner should contact the appropriate regional office of the Department. f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 Check if the following;have been done.You must indicate"yes"or"no"as to each of the following; Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X _Were as built plans of the system obtained and examined?(If they were not available note as N/A) X_ _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding SAS,located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No X _ Existing information.For example,a plan at the Board of Health. _X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance Is unacceptable)[310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_6_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203(for example): 110 gpd x#of bedrooms): 667 gpd provided Number of current residents: 1 Does residence have a garbage grinder(yes or no)_nc Is laundry on a separate sewage system(yes or no)_no [if yes separate report required) Laundry system inspected(yes or no): n/a Seasonal use:(yes or no) no T Water meter readings,if available(last 2 years usage(gpd): Sump pump(yes or no): no Last date of occupancy/use: current COMMERCIAL/INDUSTRIAL:N/A Type of establishment: Design flow(based on 310 CMR 15.203): &Td Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping records Source of information: Was system pumped as part of the inspection(yes or no): no If yes,volume pumped: gallons--How was this quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be Obtained from the system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 2003 Were sewerage odors detected when arriving at the site(yes or no): No OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 1.49 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 BUILDING SEWER(locate on site plan) Depth below grade:_12" Materials of construction: cast iron_X_40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): Joints were in good condition,no sign of leakage. SEPTIC TANK:_X_(locate on site plan) Depth below grade:_6"_ Material of construction: X concrete metal fiberglass olyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1500 Gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle: 3` Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle:_6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined:Opened covers and took measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): Inlet and outlet tees intact and in good condition.Water level was at bottom of outlet invert.Tank was not leaking. Tank does not need to be cleaned at this time. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal—fiberglass ..polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X_(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.): Box was level and in good condition.No solids carryover.Box was not leaking and water level was at bottom of outlets. PUMP CHAMBER: N/A (locate on'site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 SOIL ABSORPTION SYSTEM(SAS):_X_(locate on site plan,excavation not required) If SAS not located explain why: Type Leaching pits.Number: X Leaching chambers,number:_6_ Leaching galleries,number: Leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternitave system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): S.A.S.was located but not excavated. Soil was dry and no lush vegetation. CESSPOOLS: N/A (cesspools 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: N/A (locate on site plan) Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM-NO T FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 5+ feet Please indicate(check)methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: 10/20/2003 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: Design plan on file at Town of Barnstable Board of Health shows no observed groundwater at 132". Plan also shows a separation of greater than 5'from bottom of S.A.S.and adjusted high groundwater. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2400 Rt. 149 West Barnstable Ma.02668 Owners Name:Paul Sklarew Owners Address:2400 Rt. 149 West Barnstable Ma.02668 Date of Inspection: 11/10/2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building TANK A-1=V BARN D-B OX M1 p p7 6-2=21, ROCK WALL � Li 1 ❑ 2 LEACHING CHAMBERS i Town of Barnstable OF SNE Tp� Regulatory Services , ,,CABLE Thomas F. Geiler, Director y MASS. . 1639. ,. Public Health .Division ATfp�,�A 2 Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms-listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Z 1/20/2016 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION o'1qD0 62dj& !t/4 SEWAGE# .2DO)✓— VILLAGE Ru,tG /y4 �W -N54-St SESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 k To 0Q LEACHING FACILITY:(type(60 S D O ry -As (size) NO.OF BEDROOMS 6 BUILDER PERMITDATE: 9-3 t-0� COMPLIANCE DATE: 4 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 1// on site or within 200 feet of leaching facility) �/ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of Ieachingfacil ) Feet Furnished by �-� 1 1 t �y http://wvvw.townofbarnstabl e.us/Assessing/H M di spl ay.as p?mappar=155045&seq=1 1/2 f - Town of Barnstable Board of Health # 200 Main Street, Hyannis MA 02601 Office: 508-8624644 Susan G.Rask,RS. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. Ms. Sarah Ojala July 16, 2004 Down Cape Engineering, Inc. 939 Main Street, Route 6A Yarmouthport, MA 02675 RE: Six Bedroom Septic Design- 2400 Meetinghouse Way, West Barnstable Dear Ms. Ojala, You are granted permission to construct a soil absorption system designed for six bedrooms proposed to be constructed at 2400 Meetinghouse Way, West Barnstable. The septic system shall be constructed in accordance with the submitted plans dated May 25, 2004. S' erely r , Wa a Miller, M.D. Ch rman 6BedroomsOjala I tel.(508)362-4541 939 main street rt 6a fax(508)362-9880 yarmouth port mass 02675 down Cape enlineeriq structural design civil engineers& land surveyors June 2, 2004 Arne H.Ojala P.E., P.L.S. Daniel A.Ojala,P.L.S. land court Barnstable Board of Health Timothy H.Covell,P.L.S. 1 Surveys 367 Main Street Hyannis, MA 02601 site planning Re: 2400 Meetinghouse Way, West Barnstable sewage system Dear Board Members: designs On behalf of our client, we hereby request permission to construct a 6 bedroom septic inspections system for the existing four bedroom dwelling at the above-referenced site. No additions are planned at this time. The lot lies within an Aquifer Protection District and contains 70,518+/- sf. The dwelling is served by an on-site well. The existing permits system consists of an old cesspool piped to an overflow, which is piped to a leach pit. No variances are requested. The new septic system is designed for 667 gallons per day, or 7 gallons per day over the requirement. The base of the septic system is estimated at 29' above groundwater, based on the Barnstable Water Table Contour Map prepared by the GIS Department. The system is greater than 150' from all known abutting potable wells. Thank you for your consideration. Very truly y urs, f Arne H. Ojala, PE,PLS Down Cape Engineering, Inc. ' cc: B. Sklarew Desmond Well Drilling, Inc. Cape Cod Test Boring 5 Rayber Road P.O. BOX 2783 ORLEANS, MASSACHUSETTS 02653 (508)240-1000 November 8, 2000 Mr. Barry Town of Barnstable Board of Health 367 Main Street Hyannis, MA 02601 Ref.: As Built for 2400 Meetinghouse Rd., W. Barnstable Dear Mr. Barry: Please find the enclosed drawn "as built" as requested. My apologies for the delay in getting this to you. If you have any questions, please do not hesitate to call upon us. Thank you. Sinc ely, ally . Desmond Desmond Well Drilling, Inc. Encls. cc:Dr. &Mrs. Sklarew i Desmond Well Drilling, Inc. Cape Cod Test Boring 5 Rayber Road P.O. BOX 2783 ORLEANS, MASSACHUSETTS 02653 (508)240-1000 Sklarew Residence 2400 AMeetingihouse Rd. W. Barnstable Well Permit# W-2000-51 As built of well location(not to scale) \ z Wf11 00047/u�J 30 t�.' b di No. � ! Fee- BOARD OF HEALTH TOWN OF BARNSTABLE Application forVe[i ConotructionAermit Application is'hereby made for a permit to Construct Alter ( ), or Repair ( )an individual Well at: Location Address Assessors Map and Parcel -- ------------------------------------------------- ------ --------------------------------------------------- ---------- Owner Address �a --------- - ----------------------------------------------_------- Installer — Driller Address Type of Building �' a �C — Dwelling - — -- -- - --------- --- 0 Other - Type of Building-----=-------------------- No. of Persons------------------------------------- �'�.5 Type of Well ------ —------- Capacity---- - ---—---- -- Purpose of Well+�� a= �g��--- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate f ompliance has been issued by the Board of Health. Signed - --—-- --- --- - - -- 7--=`�-- date Application Approved B � -� - ------ ��' � date Application-Disapproved for the following reasons:-----------------------------_________—_—_----_ date Permit No. —_ ___ Issued---- t-' -- ---- ___ date---- BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS TO CERTIFY, That the In vidual Well onstructed (�, Altered ( ), or Repaired ( ) by—, � cF=�cs .c ---- -— -- — — Installer �/ ' --has been installed in accordance wQ the provisions oft a Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit Pe(6.'--�� --- n �ated�=THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE - Inspector--- —_—__— s e V7- r �/J'` i1..7•,;/, Fee-4 No. ------ ----- - ------ 5 BOARD OF HEALTH TOWN OF BARNSTABLE TApp iirat iota.*reC[ C00tructionerrrtit Application pis hereby made for a permit to Construct ( ✓(Alter!( ' ), or Repair. ( )an individual Well at: _t �I ocatton -1'Ad8resd — Assessors Map and Pazcel X/4 Owner — Address — l/v� fri r Installer Driller Address t — -- Type of Building ?� Dwelling-- - `� 1 Other = Type of_Building,--------- —----—--------- No. of Persons---- ---------------- Type of Well-----— - - -- - -= = Capacity--- ---------- - -----—— ——=— Purpose of We11=�/2�t' �' T /�,� /t/t�L Agreement: The undersigned agrees to install the aforedescribed-individual well in accordance with the provisions of The Town.of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed date- —� 4 Application Approved B -f ----- --- �_— date Application Disapproved.for'the following reasons:-------- ------------------ -------==------- • --- - date Permit No. r� -- Issued—=--��-'.. o ��— — - date y 'r+s..eG4(.ean<Pam.Q.aao.l.!Ia4...ial:ru�::i?,Ytti:4� eses6!el6�:cesiedaa:sibia6assx36�lasa•1.saa<i:•1:1eJ!ioaeosesilJclti.wsSl:weSsa4Gsr2ieY+Dis��i�u:9dts.��reali.lydesv:liMeS:4:le.@:4ea!`a:+..= BOARD OF HEALTH.. TOWN OF BARNSTABLE Certificate ®f Com0fiance-1 THIS IS TO CERTIFY, That the In ividual Well Constructed (✓)> Altered ( ), or Repaired"( ) ' \� �GI-ti•11 ` �G C� �.!�.��G Ga-i�--'sue--- -�: -- - V r"l oCJ �!( p Installer �( j�J j 7� liC has been installed in accordance v the provisions oft a Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for 1Ne11 Construction Permit l .' �'�'J'' =_✓Dated THE ISSUANCE OF THIS.CERTIFICATE SHALL NOT BE.CONSTRUED AS A GUARANTEE THAT THE WELL ' SYSTEM.WILL FUNCTION SATISFACTORY. DATE __ 'Inspector— — �,r BOARD OF HEALTH i TOWN OF: BARNSTABLE Ivell CoWruction3permit No. ' Fee Permission is hereby granted --- IL — - —----- to Construct (✓), Alter ( ), or Repair ( ) an Individual Well at: No. �/UD ��'lEC- 7r ice, �u1e (v�. c� `) / �z �:5frameG� S'eet ---------------- as shown on the a lication for a Well Construction Permit No. - -- Dated�=—�'''--�—��------------------- Board of Health DATE -- SENDER: ■complete items i and/or 2 for additional services. I.also Wish to receive thb a ■Complete Items 3„4a,and 4b, following services(for an ty ■Print your name and address on the reverse of this form so that we can return this card to you. extra fee): eAttach this form to the front of the mallpiece,or on the back if space does not pemtit. 1. ❑ Addressee's Add ss u ■Write'Retum Receipt Requested'on the mailpiece below the article number. ■The Return Receipt will show to whom the article was delivered and the date 2. ❑ Restricted Delivery N delivered. c Consult postmaster for fee. v 3.Article Addressed to: Pv, 4a.Article Number 4b.Service Type /�®° X• �� ❑ Registered Certified ❑ Express Mail ❑ Insured c �T�2 af' / ��> �L�6�� ❑ Return Receipt for Merchandi ❑ COD 7.Date of Delivery I V° 5.Received By. Name A' Y ( ) 8.Addressee's Addre s Onl if requested and fee is paid) W � 6.Sign�ture:(Addressee rAgent). iE o� • <. ,s yr, is _ PS Form 3811, December 1994 1oz5s5-s7-a-ons Domestic Return Receipt _ m R m � ru d to $,� 1 o E Er cti a rn Er �+ y � V V Q N LL $ m v LL 'Z O U c ti ti Z` t'a ¢ oo y \ �F �- �, ; V5 o y N rrl v,t• ° ?d n y2y�� m ' �.C m ai ' O is n ZYYII i� LL y �0 'm a N V) � o Oo ° t\�_ o ari a ai `m m m O o 9 Z o o U Cn ¢ cc Cr o a- o- 9661 ludo'009£ Department of Health, Safety, and Environmental Services EVE ,.� Public Health Division P.O. Box 534, Hyannis MA 02601 • BARNSPABLE. MASS. A O i G Thomas A McKean,RS,CHO gam{: 04 Director of Public Health September 2, 1998 Mr. Paul Sklarew P.O.Box 606 W.Barnstable, MA 02668 NOTICE TO ABATE VIOLATIONS OF THE TOWN OF BARNSTABLE REGULATION REGARDING FUEL AND CHEMICAL STORAGE SYSTEMS Our records indicate that you have an underground#2 fuel oil tank located at Meetinghouse Way, W.Barnstable MA 02668 . This tank is listed on Parcel 155 on Assessor's Map 045 and registered as tank tag# 609. This tank is not located in a critical zone of contribution to our public drinking supply wells but is 30 years old or older. You must have your underground tank removed within 30 days from the receipt of this order letter. For the removal of the tank you must first obtain a removal permit from the Fire Department. I have enclosed tank removal information for you. Upon removal of your tank, please return valve tag 9609 to the Health Department. You may request a hearing before the Board of Health if written petition requesting same is received within seven (7) days of receipt of this notice. Sincerely yours, o as A. McKean Director of Public Health Enclosure: Tank Removal Information e''s�y .PFtQ,gS°c•f t7w � r'1"" p;'"5 vr4 is e r vct u":F•1 �. 7 , e • h1+•w+S= r �" •X t •,J-t,.1 4'�+w•s, ,Tk s'. m a�'`ts 3 i.'.�" i rx.. e V"¢ '' .fi ax .x lop µme ` WEST BARNSTABLIJ FIRE DEPARTMENT 5 WEST BA RNSTA_BIE, M44SACHUSETTS 02668 e'A CVZ too, ' Septeml.,6r 15, 1993 '10H'N P. JENKINS FIRE CHIEF r EMERGENCY- 362'-3131: j. 1301NESS 362.32e1 Thomas A:.-McKean, Director ' f' r •'-Heal`t Department . ' . �. Town`:of Barnstable ' j r r'367 'Main,,Street Hyannis ,. :MA 02601 f� 6` t ` RE `UNDERGROUND TANK ]REMOVAL NO'Ti>�'ItxYON .e sr iir4 r F ZH Dears Mr,' 'McKean, • >` 3r ' Tis ; is to notify . you of the remvv of an underground soragef s -}' tank:';°T.he_ following information is p: ,vi.ded for ,�G�.�r Cen�Ienien�oe`„ F WBFD REFERENCE: 193 89 DATE,! OF REMOVAL: September 15 , 1 9'ai x 'STREET LOCATION: 2400 Meeti nghousE. Way (Route 1 49 ) { :PROPERTY OWNER: John Anderson Dal i s , > TYPE�,'OF 'TANK: 500 gallon steel,, round t Y �; PRODUCT: #2 Rome heating ;I,el '1,TANK":REG. TAG: 609 ' Chief Qenk'ins from' this Department, s ervised the removal of this, 7' , tank;, ' The tank was -solid, '-and thej ,h was no indication of any: y r � *� f,r�•` leakage from. the tank. ' ank. i 1 � n- < ThisF . tank has been replaced by . a I!75 gallon tank. w,ithiri the' i asement of r , th e dwe��Ing. �Ta4 this =Department ' s knowledge, thE� �; are- .no other '`underground,, x w , ,'` t 'C k'v.:w,+ts ! i d'.: t"' s_• ,rat' y .w , -orage gt Ti anks onr this remises:: z i.LQ t-,xiA r 'T{;.t�' 'wg+� `# s,Mr_` <� ,f "<i sr� {r: ;•.i cam' r a . -_�. + z,F " Sin er y yours r ,: 5•.•4�',?`�'A' ^```ls"5nl �,..:"�"ay� j�C ' � 4� x TM �, +. t kf t S f;. i , .:i a -# F Rey: , a.v�.. x.k7 t , Jo enkris; Chie> { of .Dpartment ' A aR+`.,. .i'. ;'.. , , id rt •per e: "44 rr J F' �3 , '•s;t,N��,C<n4"x{r•,}•N� i,, v rr r � N''' i,''a* , , + j> #rr = Y t4�� j,\ � s. r ' —'.-r'•� la` _ �„y :A"'*t< i, t ,r \ f st rin 9 ••;t 1 •. r 1 �. tY� yKA3a ,tr-Cr} �' ' <:,g ' i F �.,r'�rt.✓itt' `t"�.,:'�{�v� .":xt vzf<�ta .. :. .. Rir dK�'fi )<'y�•, r w��i:7'�ii��' _ ,':f,^s. ., 4 Barbara Sklarew Box 606 West Barnstable MA 02668 Glen Harington Health Department Town of Barnstable PO Box 534 Hyannis MA 02601 September 23, 1998 Dear Mr. Harington, I received a letter from the town of Barnstable requesting that I have my storage tank removed. I have enclosed documentation that the storage tank was removed in 1993. If you have any questions, please feel free to give me a call at 362-7796. Thank you very much. Sincerely, Barbara B. Sklarew encl. l:OCATION �' SEWAGE PERMIT NO. `j �, L d P. -4.,� N�� VILLAGE INSTA LLER'S NAME a -' ADDRESS Sk . � 8 u.IL.Df R 'OR OWN EN. ..� .DATE PERMIT tssu.fu i DATE COMPLIANCE ISSUED l gq r 6.0 sd f/ �t rS-�7'� 7 � R ' � •J No. .........T'I2 _ Fps......................... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH Gtn.....................oF.. !'n .... Allphratiura for Uhipas of Workg C ontitrurtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair 4) an Individual Sewage Disposal System at: V4 00 12'1 .iri. l taosQ��...............--- .._ ------------ L cation-Address Lot-Not R4.... H r G!ga rrskp" Owner Address W _�...� _........ -----------. __t �n..5 -+.._.tug .._ ----------------.......... •....--- Installer Address dType of Building Size Lot......__--------------------Sq. feet U Dwelling—No. of Bedrooms.......... _..__Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ................................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...._............... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit............_....... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••••••-----••-----•---•----•-----•...........................••--•--...-••------•---••--•••--•--...........----....__...--•--••••-----••-----•....•--•-_---•- 0 Description of Soil................-.......--••-•------•-•------•---------•----•-•--•-----•-••----------------------------------------•-----------------------••••--•..._.----------•-•-•- W V ---•--•-••--•-•------•---------------•----------_----_--------•-------------_-_____---------•--•---•--•-------------------•--•--••-•--------••-•-------•---------••----•----------•--•-•--------------- W ] U Natur of Repairs or Alteratio s—Answer when applicable.-��*".__&�-?�I--`► GCCI. !Y'__1�±.! _..._______- Va- _.0 _ ...: --•------------•--_-__----••---•--------••----__---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I IL LE 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 of health. Signed... .... .._.... at Application Approved BY •--•--•-•--•••••-•••----- ....'= __ �,. _- ........ Date Application Disapproved for the f olloz ing reasons--------------- ......_............ •.............................................. ---•--•------•--•-. ..............•------------._....----•--•-•----•••--•---------------•--•------------------•-••------..._... 7� Date Permit No..............��_`ra... -.. ...... Issued....................................................... Date l THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH e rt)S } �... ..0 .. OF....'...............�OIE......---------------.........------..._........_........ Appliratiou for Disposal Works Toustrnr#ion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (�) an Individual Sewage Disposal System at: i Location-Address or .. Owner Lot No / 1 V I f..N�� ................l�c't (�ias� cbp Address �i 9 /�j �ls/YLCn .3 ��lCjltl f r2P�' (tJp`� Llstrilat (�_ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.........a..............................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria QI Other fixtures ---------------------•••--•-•-. . w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No___________________•• Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1____--_-______minutes per inch Depth of Test Pit.................... Depth to ground water..................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' -•-----•---------------••-••------..........------------...•••---------...........•----•-----•.......-•-•-•-----...----••-•-•-•--•-...---•••-••--•-•--.-•---- 0 Description of Soil............................................................................................----------•------•--------••--.....----------------•-•--•------•---------•- x U w V Nature of Repairs or Alterations—Answer when applicable.. �a ___�.00---___ ! `?. �¢._ ! ............. A.-- .C<kC"".eP.---•---•--•--------•------------•-•--•--•--•---•-----------------------------------------------•--------------. Agreement: U The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 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 of health. G, Signed---- `=k o ---------------• 3 • . . --—-- / Date Application Approved B �'-:'�.�-.�: 1 g= = ......................................... .' / ] Date Application Disapproved for the following reasons---------------------------------••-------------------...---------------------------------------•••........---•- ......................•--•-----••-••-•--••...........---•••-•---•-•-•-•-----•---•••••-•--••-•-------...•.•-••----••-•-•....•------------------•-...•--••••-••••--•--••••--------------•••••-•----•--•••- f Date s _ Issued.-•---•-•---•------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD � OF �,,H`EALTH �.O1w.rt.....................OF.... ! Y7:5 (I.L....... (Irdifiratr of Toutpliattrit THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired {1) by............... . .n �2n........................•..........•...... .....,-----------------------------------------------------------------..-----.......------------......------. © 1 Installer _ has been installed in accordance wl the provisions of TITIF 5 of The Stata.mta Code as describe�n the application for Disposal Works Construction Permit No:��z..-__._1__'� �...... dated_ . .. .. -,�_�;�./ ------_-_•_-•---. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT-THE SYSTEM WI C SON SATISFACTORY. — DATE [(( ¢¢ `........................................... Inspector....a::......................................................................... s THE COMMONWEALTH OF MASSACHUSETTS\�y - BOARD OF ,,{{..,.HEALTH _. 7 ......... ................................. No... 1 Z. FEE--- -a�.......--•--- Disposal Vorks Tonu#r ion rrutit Permission is hereby granted....... ': v> 1�r---------•--------•-------•-------------•-----------••-----------------------••----•------------•-------•--- to Construct ( ) or Repair ��n Individual Sewage Disposal�System at No...-r°�--Sn (Y`zr11 ass ;->2."r r 1 Street as shown on the application for Disposal Works Construction Permit N� Dated..-- /o��................ � - ---•------------ Board of Health' J FORM\1255 A. M. SULKIN, INC., BOSTON d TOWN OF BARNSTABLE r UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS' A� J� ASSESSORS MAP NO. /.$� � PARCEL N0. 0�5.� ADDRESS:.1' QQ VILLAGE. _ nn CONTACT PERSON PHONE NUMBER 31 2 r O/Ow 212_2sw LOCATION OF TANKS: . CAPACITY: TYPE--OF- FUEL AGE: TYPE: LEAK OR CHEMICAL: V DETECTION SYSTEM! DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. � r�� " �� `� S �. � � x ��(„s,.S t � i . 1 � 1 a�' i t I I� 1 Ns-LL i lV +'I � 1 ' i LP 04 1 t - t I i "ALLx�� 2 fLOOf-1 i is or cL O I i l4k 5 �,� TOP FNDN. AT EL. 59.1' SYSTEM PROFILE TEST HOLE LOGS I .., - ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) KE 6� PROVIDE INSPECTION PORT WITHIN jj ACCESS COVER (WATERTIGHT) TO Z 6 OF FINISH GRADE ENGINEER: A.H. OJALA, PE 4. 56 MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 52.0' WITNESS. DAVID STANTON, RS �P 2" DOUBLE WASHED PEASTONE 10 20 03 NOTE: MIN. 2 * RUN PIPE LEVEL � \ DATE: / / � INVERTS OUT 56 8' FOR FIRST 2' ' < 2 MIN/INCH OF DWELL. PROPOSED 1500 3 MAX. PERC. RATE _ (ONE LINE MAY GALLON SEPTIC 7cJ' // 49.0' CLASS I SOILS P# `omD A"E Y" INTO THE 54,0' �� TANK (H- lO ) GAS �� OTHER) 48.5' O Cl 0 m m ED BAFFLE 48.67' �� o 48.170 p O m m O 0 0 0 ELEV., 5-8% SLOPE) �6" CRUSHED STONE OR MECHANICAL S 0 m 0 0 Q m ED m I� O Q 51 COMPACTION. (15.221 [2]) MIN o03$ _ 2 � � 0 � � 0 � � i� '0 46.17 A e��1 DEPTH OF FLOW = 4 ( 6 % SLOPE) ( 1 7. SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED' STONE SL TEE SIZES: INLET DEPTH = 10" 12" 1OYR 4/2 OUTLET DEPTH = 14 B SL LOCATION MAP NTS " FOUNDATION 4$' SEPTIC TANK LEACHING$3' D' BOX 27' FACILITY 24" 10YR 5/6 49 7 *THE INSTALLER SHALL VERIFY THE 3 4 ASSESSORS MAP 155 PARCEL 45 LOCATIONS_ OF ALL UTILITIES AND ALL /5A' 5.47 C1 BUILDING SEWER OUTLETS AND ELEVATIONS y PRIOR TO INSTALLING ANY PORTION OF + 54.8 LS SEPTIC SYSTEM Erg �4.3 5' 46" 47.8 S 2.5Y 6/4 , g5 `Lh• 1 1' + 40.7 PERC C2 55.3,/ I 55A I FS / / g0 `S6 / /55.7 �� 2.5Y 7/4 +55-B-- - -k 55.3 * 55. 9 55.1 132" 40.7' 56 \ "' NGWE 5�� \\ BENCH MARK - CORNER OF\\ + s7.4 CONC. PAD ELEV. = 56.8 NOTES: \ \ + 57.5 SFPTIC DESIGNI: (GARBAGE DISPOSE? IS NOT Al LOWED 1 . DATUM IS APPROX. NGVD h \ \ DESIGN FLOW: 6- BEDROOMS (110 GPD) = 660 GPD \ \\ + sa.a � 660 - 2. MUNICIPAL WATER IS NOT AVAILABLE + 56.3 \ + s�s + s8. o USE A GPD DESIGN FLOW \ 68 ate' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. \ \ 5.1 SEPTIC TANK: 660 GPD ( 2 ) = 1320 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- i o \\ \ EXIST. DWELL. + 55. �• USE A 1 500 GALLON SEPTIC TANK 5. PIPE JOINTS TO BE MADE WATERTIGHT.� TF = 59.1' .3 546 M \ LEACHING: 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. \ \ 7'a 2(58 + 10.83) 2 (.74) = 203 ENVIRONMENTAL CODE TITLE V. >s + 56.4 \ ++5 \p�.0 6 5T.1 s4 4 SIDES: - 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT sJ 2i + 5 .4 58 x 10.83 (.74) 464 TO BE USED FOR ANY OTHER PURPOSE. 7.4 / 7 T 57 v`° + a.7 �' BOTTOM: ,, + 4 �- 557 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. + 51.6 TOTAL: 902 S.F. 667 GPD 9, COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT \ \ �,+ 57.4 USE (6) 500 GAL. LEACHING CHAMBERS (ACME OR \ \ CONC. wAL + s s7.2 3.4 / INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED W Cn EQUAL) WITH 3' STONE AT SIDES AND 3.5' AT ENDS FROM BOARD OF HEALTH. 6.9 572 48" OAK ` REA OF F%:' , �, 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING SEPTIC SYSTEM 56. + 53 \ A .'� I( DIRT & \ 7.5 IVY AND 11. ANY UNSUITABLE MATERIAL FOUND MUST BE REMOVED FOR \ GRAVEL \ TREE Ln 5' AROUND SAS AND REPLACED WITH CLEAN SAND DRIVE \58 4.6 +-.53.8 51. 52.0 + 49.7 LEGEND =�- --- + 5 . TITLE 5 SITE PLAN i3 53.4 100.0 PROPOSED SPOT ELEVATION OF .wry 40 s 2400 MEETINGHOUSE WAY GARAGE 57.1 +., .8 `� � 24" TREE 50.9 o -- ;+ 52.5 100x0 EXISTING SPOT ELEVATION (�P .9 IN THE TOWN OF: + 4 960 1001 PROPOSED CONTOUR (WEST) BARN STABLE 53.0 100 EXISTING CONTOUR PREPARED FOR: BAR BARA S K LAR EW �. CP CID tuol LOT 1 __ E 70,518t SQ. FT. 5 30 0 30 60 90 + 51. BARD OF HEALTH \ + 5 MA MAY 25, 2004 APPROVED DATE SCALE: 1 = 30 DATE: EXIST. SEPTIC SYSTEM SHOWN off 508-362-4541 + AS PER INSTALLERS CARD fox 508 362-9880 tHOF I _'(H OF pfgss9C Off, ARNE H. tic ARNE - N down cape engineering, Inc. �� OJALA �^ H. o CIVIL OJALA � CIVIL ENGINEERS No 0792 A No-02 LAND SURVEYORS °F STEt��G t Fs se ` �� >k'A 939 gain st. yarrnouth, rya 02675 I 03--272 ARNE H. OJALA, P.E., P.L.S.