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HomeMy WebLinkAbout0068 PACKET LANDING WAY - Health _68 PACI ETT.LANDING, O u F T41t J f,% C�lk d4el s C r W Un ins C�1��, �p �� �,�jN+� �� ► - i{M fvi j 3113 Via. or � P 1 a i 1 e � i Commonwealth of Massachusetts 0 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is West Barnstable ✓ Ma 02668 6/26/2016 required for every page. City[Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:out for When A. General Information i filling out forms to 9 Z on the computer, use only the tab 1. Inspector: key to move your cursor-do not Jason X Souza use the return key. Name of Inspector American Excavating Contractors LLC Company Name 27 County Rd Company Address Mashpee Ma 02649 CitylTown State Zip Code (774)836-5774 S113536 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 6/26/16 spectrstem ature Date The nspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 loe VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5.1 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 page. City/rown 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: System appears to be in good working order. i 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 pox for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Land*.ng Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 page. Cityrrown 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: N/A *'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: N/A I D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ' ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5in3•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is West Barnstable Ma 02668 6/26/2016 required for eve page„ every City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equatto 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 16,000 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-311'c Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on.a separate-sewage system?(.include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: House was unoccupied Sump pump? ❑ Yes ® No Last date of occupancy: unkown Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist i Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 page. Cityrrown State Zip Code Date of Inspedion D. System Information (cont.) Last date of occupancy/use: Unknown Date Other(describe below): House.has been abandoned-for multiple years and_is.now being.restored.in preperation for new occupants. 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•3/13 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information every is required fcr West Barnstable Ma 02668 6/26/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Installed in 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ®cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): No leaks present. Septic Tank(locate on site plan): Depth below grade: 1.5 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: 10 foot 6 inches long by 6 foot 9 inches wide Sludge depth: No sludge present t5ins•3113 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 M '< 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is requiired for every west Barnstable Ma 02668 6/26/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle No sludge, only clear water present Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? N/A Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): N/A Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: Unknown Date -t5ins-3/13 Title Official Inspection Form:Subsurface Sewage-Disposal System•Page 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 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.): System seems to be in good working order. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A p �' gallons Design Flow: N/A 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.),. N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name requred fo is West Barnstable Ma 02668 6/26/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evedence of solids carry over. System has been unused for multiple years. 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: t5in:•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s ��< 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators ❑ 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.): N/A Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 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.): System seems to in good working order. No evidence of ponding. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every west Barnstable Ma 02668 6/26/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 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: Installed a monotoring well. Groundwater present at 7 feet.Top of S.A.S was 1 foot below grade. Units are 2 feet tall. Before filing this Inspection Report, please see Report Completeness Checklist on next page. -t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Amt Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r 68 Packet Landing Rd Property Address Nick Souza Owner Owner's Name information is required for every West Barnstable Ma 02668 6/26/2016 page. City1rown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 { F _ � 1 ;� Vol �S F. T 0 few H, y 046 y e ' oil •. Edd H'T - � s ! 3 t i r. Ip OF1HE► Town of Barnstable O Regulatory Services 9 MA MSS. Richard V: Scali, Director 1639• ♦0 pTEDnw'�°' Public Health Division 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 26,2016 Shay Environmental Service PO Box 1576 Mashpee, MA 02649 Carmen The Health Department is returning the inspection performed on 6/12/2015 for 68 Packet Landing and received on 3/28/2016 via E-mail, due to multiple errors. For example: 1. The wrong inspection ection form (t5ins.11/10) was submitted; you must use the newer form (6.ins.3/13). 2. Regulations state"that the system Inspector shall submit a copy of the inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing the inspection..." Please make corrections to the above mentioned discrepancies as soon as possible and return corrected inspection t the Board of Health. Thank you as A. McKean, CHO, Age the BOARD OF HEALTH f June 14, 2016 Shay Environmental Services PO Box 1576 Mashpee, MA 02649 ` V Carmen: RE: The inspection report on 68 Packet Landing. 1 n tom--- � The Health Department is returning the inspection performed on 14 4R:I--54W4�- ia - to ulti S. (l �Q e. • The wre b pitted—you=m-ust_use.-the newer fefm— ''`` (t5ins.V13) ,�Q. �-2_ `(ku q I�ru,ti,ri U • Regulations state; ... that the system inspector shall submit a copy of the inspection report W to the Approving Authority(Board of Health or DEP) within 30 days of completing the �M inspection..." is C9� Please make corrections to the above mentioned discrepancies as soon as possible and return corrected inspection to the Board of Health Thank You Thomas A. McKean, CHO, Agent for the Board of Health -mot' l If doh` 7 2C'Gf vl � � Orr �.v V 1' �Lj J '� e� Carmen Shay Shay Environmental PO Box 1576 Mashpee, MA 02649 Dear Carmen: The Health Department is returning the inspection performed on 6/12/2015. This was received in March 2016—EIGHT months after the State required due date and is on an old version of the State's form. As you are aware,the State requirement state that..."the system inspector shall submit a copy of the inspection report to the Approving Authority (Board of Health or DEP)within 30 days of the completed inspection..." This inspection report must be redone onto the State's newest version for septic inspection reports (report "t5ins.3/13). Please make sure the ground water information is complete, as well. Thank you. } r CoLmonwealth of Massachusetts S Title 5 Official Inspection FormG� A . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments4 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA [V_ 02536 -_ 6/12/15 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 s filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Carmen Shay use t-te return Name of Inspector key. Shay Environmental Services � Company Name P.O. Box 1576 Company Address rem, Mashpee MA 02649 City/Town State Zip Code 508-294-7498 3080 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ❑x Fails ❑ Need -F"?i rther Ev n by the Local Appro ing Authority 6/12/15 r) * 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 1000 TO or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be'sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. `This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under. the same or different conditions of use. t5ins-11/10" Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of W kp VJ i Commonwealth of Massachusetts u; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Packet Landing Property Address Donald Roberts Owner Owner's Name informat on is UJ ^� required for every Barnstable MA 02536 ' p 6/12/15 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 S /Iz on the computer, use only the tab 1. Inspector: key to rrove your cursor-do not Carmen Shay use the-eturn Name of Inspector key. Shay Environmental Services r2b Company Name P.O. Box 1576 Company Address Mashpee MA 02649 City/Town State Zip Code 508-294-7498 3080 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 ❑x Fails ❑ Needs,further Ev In by the Local Approving Authority 6/12/15 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �� •5 f r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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): l5ins•9 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 B 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments uM 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: 0 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: 0 Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Packet Landing Property Address Donald Roberts Owner Owner's Name informaVon is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. / ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance:. **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑x Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 5 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. Cityl-rown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑x ❑ 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. ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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. ❑x ❑ 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. 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑x Were any of the system components pumped out in the previous two weeks? ❑x ❑ Has the system received normal flows in the previous two week period? ❑ ❑x Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ 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 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: ❑x ❑ Existing information. For example, a plan at the Board of Health. Z ❑ 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): 330 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Single Cesspool Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑x No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Z No Laundry system inspected? ❑ Yes ❑x No Seasonaluse? Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): ----- Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: unk Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•1 I/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts =a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: unk Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ❑x No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑x Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 68 Packet Landing Property Address Donald Roberts Owner Owner's Name informa-ion is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: El cast iron ❑x 40 PVC El other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): No evidence of leaking pipes or improper venting Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑x concrete El metal ❑fiberglass El polyethylene El other(explain) rt If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11;10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts ui v Title 5 Official Inspection Form =� Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 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 18" Scum thickness 1/4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good conditions, inlet and outlet tees/baffles in good condition. _ Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete El metal ❑fiberglass El polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11,10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass El polyethylene El 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 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 licuid level above outlet invert Present 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.): One outlet to trench 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: 4 Infitrators and stone. System is within groundwater table. t5ins•11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts L. W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑x 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.): 4 Infitrators and stone. System is within groundwater table. 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 0 No t5ins•11I10 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 w 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 F c 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑x hand-sketch in the area below ❑ drawing attached separately TOWN Of B"9BNSTABLFs LDCATION EB -r Cv F:%p �.� sr ooc.#_Y�-Y.3 ViLL_ACE u ,�I/!.31rd/-,4-1 ASSESsc Lcs mAP&LOT LL\sTnL.L.r:xsN:LY1L•�PL1oa=Nn. �a!->��1�ir�€y: 77/-93 SE:1-11C TANK CAPACLTY„�3CZ•C- ,(� - LEACKUNG FACLU TY:UyR J —�-�..I�.-_.___ls�.iuJ� ��•Y l o X 1 No-0-BEDROOMS 7 BUMDL•R - P.EKl,rr o.NTr: '1�--ai+Q"7 cumi-LLANcu DATE....... `•,pnfMILJII L1iSWa'e Bs:twccn ch.; . M,uirnun Adjuc:xi Grranrlwxer Tnbk::nd B(n(rur ufl.cac::ur„g Cailiiy _..,, Eec: Nirot_Wn1er.5ppp1y WOL AnCLe3L:ai�FEtiiLy (if:uy ne;la trice un si:c s:c wi0iir i:.A rct r:S leachini facLGy-} Fsct E�xe z 54aflao9 aW l.eE�kting Facilii}fLf arty weganA.c e>;ia wi�in:kr&+•s cf lea:,hins:eciiiyJ s�_L 11aznl3h2C Ly ,37 1 .40 A -1- ,aE JL FtJ �ry�9r I f— -.4 I I f I L I t t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 0 Check Slope Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water: 3 to 4 feet based on adjacent wet stream Please indicate all methods used to determine the high ground water elevation: ❑x Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑x Observed site (abutting property/observation hole within 150 feet of SAS) ❑x Checked with local Board of Health -explain: Observed water in crawl space and adjacent stream. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Packet Landing Property Address Donald Roberts Owner Owner's Name information is required for every Barnstable MA 02536 6/12/15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑x Inspection Summary:A, B, C, D, or E checked 0 Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Parcel Detail Page 1 of 4 • - THE ell V, DARL 1639. tj a Parcel Info - g. Parcel ID F179-017 Developer LOT 14 „ Lot Location 1168 PACKET LANDING WAY I Pri Frontage 304 Sec Road L I Sec Frontage . .�, ,.w �I ,.—Village West Barnstable x) Fire District W BARNSTABLE I Town sewer exists at this address NO I Road Index 1200 {� e Asbullt Septic Scan: Interactive 179017 1 Map ' '' R } s - Owner Info owner US BANK TRUST NA TR I Co-owner %SOUZA, NICHOLAS A Streets 169 FOX RUN I Street2 City ICENTERVILLE I State FMA I zip 02632 Country Land Info . Acres i0 61 I use Single Fam MDL-01 _ I zoning RF I Nghbd e0f 105 � Topography ILevel I Road Paved .I Utilities Gas,Well,Septic I Location ) Construction Info =v` . Year F1971 I Roof Gable/HipI Ext Wood Shingle Built Struct Wall Living 1236 I Roof Asph/F GIs/Cmp I AC None I _ Area Cover Type 3A5 Style I InsIDrywall "I Bed 3Bedrooms I t y Wall Rooms �eBMr •�, Model;Residential I Floor.Hardwood Roms 1 Full-0 Half saB Grade Average Minus I Type :Hot Water I Rooms 5 Rooms Stories 1 StoryI Heat Electric Found Typical I 12 z Fuel ation Gross 2432 Area�,....,.. .. Permit History— _ u 26— 1/1/1973 Addition B15830 $0 3115/1973 12:00:00 AM WBADD'N http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=12348 12/7/2016 Parcel Detail Page 2 of 4 Visit History , , - v, €, 7/9/2013 12:00:00 AM Denise Radley In Office Review 3/28/2012 12:00:00 AM Denise Radley' _In Office.Reviews 11/5/2008 12:00:00 AM Paul Talbot Cyclical Inspection 8/25/2000 12:00:00 AM Paul Talbot Meas/listed-Interior`Access Sale s Histo e 1 9/25/2015 US BANK TRUST NA TR 29161/23 $266,200 2 12/23/2002 ROBERTS,DONAUD C, + >�,a 16133/�0> " "'. $0 3 8/25/1997 ROBERTS,DONALD L&HUFFMAN-ROBERTS,BRE 10916/297 $115,000 4 12/15/1993 r WARDWELL,NEAL A TR " 8973/t27„ .- V $1 5 4/15/1987 GAUDET,MARLENE A 5666/165 $1 6 12/2/1977° =w ;GAUDET,JOHNR'&MARLEN ,A- 2827/84 = &m' ^ p ;$0 7 6/1/2016 SOUZA,NICHOLAS A 29689/242 $115,000 a vt n� �'°. Assessr>aent History � 1 2016 $89,400 $28,700 $2,000 $115,300 $235,400 2- 2015 - $87;700 P $28,400 x7$2,400 _.�� `,'u$116,100 ,r �234$00 3 2014 $87,700 $28,400 $2,500 $116,100 $234,700 '4 2013 -'�'$87,790 . �' $28,400 $2,500/" , s $116,100:, $234,700 5 2012 $87,700 $27,700 $2,000 $116,100 $233,500 �6 �`''2017, $1t2;500 $3,20Q $900` „0$116,1t m <$232,700' 7 2010 $112.400 $3,200 $900 $116,100 $232,600 8 „.- 2009 $105,800 , * $2,600 `a_ �'. $400' $151,800 $260;600 9 2008 $125,900 $2,600 $400 $158,200 $287,100 11 2007 711 $125,500 `"'$2,800 ­$400° $158,200 `' $286,700 12 2006 $112,000 $2,600 $400 $166,800 $281,800 13 2005 $104,404 - F" _ $2,500, •' $500.': .$113,700 �� - . $221`,100 14 2004 $84.400 $2,500 $500 $113,700 $201,100 15 2003 �_ $75,400 $2;500 _ $500 $64,00017 $142,400 16 2002 $75.400 $2,500 $500 $64,000 $142,400 $76,400- $2,800,:` $$00 ,r d $64A T $142 400 18 2000 $57,200 $2,300 $200 $47,900 $107,600 19 .� 1999 " '' $57,200 F $2,300 ``$200 ,` s - $47,900 _.�-`�� $107.600 20 1998 $57,200 $2,300 $200 $47,900 $107,600 =22 1997 �k '$61,70Q b °; ': `$_� �. a ; , 17� $43,100 - `, e `$105500 1996 $61,700 $0 $0 $43,100 $105,500 '23,- "� ^:J995 24 1994 $59,300 $0 $0 $43,100 $103,100 25 '.1993 � '` .-$59;300 �' $0 ° $0 n$43,100.= $103;100 26 1992 $67.500 $0 $0 $47,900 $116,200 27 '` 1981", ��. $68,8¢30 0 ,$0 � �' $51;100;` ` $120500` 28 1990 $68,600 $0 $0 $51,100 $120,500 29 ,1989 f _ $68,800; € e`'$0 $0 r „ $83,800: $133,200 30 1988 $57,000 $0 $0 $34,600 $92,400 31!• ?�1987. _' $57,00Q �'p,� $0a:' 0$34,80 , 32 1986 $57,000 $0 $0 $34,600 $92,400 . - tOS http://issgl2/intranet/propdata/ParceiDetail.aspx?ID=12348 12/7/2016 Parcel Detail. Page 3 of 4 f- a � �'.{ �^' � aa� � xya•a'`kin r ar? '�. ,� �� � St, J t - At Y _ r y Y=4 :,a a.f r � r F F http:rlissgl2/intranez/propdata/ParcelDetail.aspx?ID=12348 12/1/2016 Parcel Detail Page 4 of 4 { EP, ,E h � MOPT6ABE 6ERVICCb�Z• G -t A8A4T BUTIUG 08 ,q7� wGT.I,,Rq,vR wn� 6, n http://issgl2/intranet/propdata/ParcelDetaii.aspx?ID=12348 12/7/2016 Town of Barnstable Barnstable Regulatory Services Department A&AnmftCft �RVSTaB� : g rY p 1 ► , °6 9 ��� Public Health Division 'OrFc °i 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO December 14, 2016 Nicholas A. Souza 68 Packet Landing Way West Barnstable Way, MA 02536 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5. The septic system located at 68 Packet Landing Way, West Barnstable, MA was inspected on June 12, 2016, by Carmen Shay, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system FAILED under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Backu f sewage into facill or system component �ooverloadedor ged SAS or ces ol. You are ordered to repair or replace the septic system within Sixty (60) days from the date of this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL# 7006 2150 0002 1038 6537 Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\68 Dale Avenue.doc r 0 j t Yw Yy�iG,t O _ u7W7-Y-__ .. vvrevr tc�crr� "S�G�l�O1V A.1 I s� --.oRcu I b.d FLOOR R KQ ;: Vv w��4titrtle,�tuv�Xvi.cei� ` ADD 1110y6a kTEIzAM(t.S i9 . Brace Devlin 77Z.38-0777 "3T 9A R1J51'n(bLE%�K �� � S�e � � 1 � . �� Q � y Q��� Coy �f / S��-� �, TOWN OF BARNSTABLE LOCATION SEWAGE # �138 VILLAGE ����/�PJA'�`d? ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. G'�'�✓� � �d��7; ��9-3�� SEPTIC TANK CAPACITY 1A)CC LEACHING FACILITY: (type) ''i 'iZ.L--9C 14— size W-Y 1 b!C1 NO.OF BEDROOMS PERMTTDATE: J1 -OL I-LI 7. COMPLIANCE DATE: Qom_ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i !� CA r ar 3 ara'0 f 'lep4.r 3 + J No. , Fee THE COMMON ALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mi.5poal *p5tem Construction Permit Application for a Permit to Construct( )'Repair( )Upgrade(v)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4,140/!,0 Awl Owner's Name,Addre�`s and Tel.No. /Q®fJ�0 15 Assessor's Map/Parcel �� ,Q� /�/LO Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. bf7WG0111 cdfs, 71)-�J�9 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder Other Type of Building Ae,0 � No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 3® gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /B0O4d1 %9_J`i7� Type of S.A.S. y A",), I% �B�wX3�GX'Z� Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last.inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this Bo f He h. l Signed. Date Application Approved by Date .40- 2 Application Disapproved for the following reasons Permit No. Date Issued �� No. r ,.� ,.�-� Fee THE COMMON. ALTH OF'MASSACHUSETTS - ntered in compiter:_ Yes - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS &Plicatiou for nigpo!6ar *pgtem (E.ouaruction j3ermit Application fora Permit to Construct( )Repair( )Upgrade(/ )Abandon( ") `❑Complete System ❑Individual Components Location Address or Lot No. /_�' J�QG � � �d Owner's Name, dar/eess and Tel.No. Assessor's Map/Parcel � y�n.r��q � J Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/- Type of Building: l � p Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder Other Type of Building No. of Persons I Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 3t6y gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank IAV A ' / X/5�`f � Type of S.A.S. �d�'%/j�'✓ZG'/'S ����o��' Description of Soil " 4 f Nature of Repairs or Alterations(Answer when applicable) r/r/e J7 4 Date last inspected: F Agreement: The undersigned agrees to ensure the constructiorland maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued thi Bo f Hea• Signed r - Date Application Approved by - ' !' h y Date Application Disapproved for the following reasons Permit No. 7 ' 3 { ;r ',",Date Issued t ————————————————————————————————— 7 —— Hp THE CO M �WEALT •OF MASSACHUSETTS 7 --D l BA -1,TABL,E,,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage.Disposal System Constructed( )Repaired ( )Upgraded(✓) Abandoned( )by- AD/, at p�1 } /7 has been constructed in ac--ordance with the provisions of Title 5 and the for Disposal System.Construction Permit No. 'a,. r- ,; dated ,�0��`.� 47j`/ �a�ST Designer - Installer ner g The issuance of this permit shall, of be construed as a guarantee that the system will f ction as designed. Date Inspector 9 . _•, No. --—�,�—---------------------, —w 1 '/7 Fee -+� THE COMMONWEALTH OF MASSACHUSETTS /A PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Digpooal bpztem Construction permit Permission is hereby anted t Construct( )R pair( �)Upgrade )Abandon( ) System located at $ GTLi�e1G�'/1�'/� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: % �-� Approved by � ,•t Fell Locn�-jm�r rV��l%�.� ,06 �o \ �Q' a"'Pow '00046�� b eil NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AIND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANSI hereby certifi�that the application for disposal works construction permit signed by me dated 16'A-1l1yr . concerning the property located at iq-AG,�e meets all -`rre `ollowing criteria: x— I^ere are no wetlands v ithin --00 "et o _ e orocosed seP ric systern �1here are n0 Dr?V3t wei1S R iirilIl i i) _Oet of ale xrjoosed septic- s-,stern ne o0s:r Ved ='roi ndwater:tote :s - :or ?r�3i.'r Oetovv, -rt0 Oon T : ir _ - - _ 0:�: of ^.,..' :03G��..c_ ,73C:17 [� here is "!0 ;ncrease m :���'.' 3n_0.'Or '3Il?e in -1s 7ruos0'3 bf - , _ I SIGNED : DATE: I LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan. this plan should be submitted]. t:. w .S�FyN� W .Fr'Syw,:kr.3s *Qs',, S 2C�. �� x .{.. ,ry7. .y +r+.�, r 'w-. , + e sst *w 2 # e "L : t - ` `%r't��s� e, ,r;.:s'.. ,,�„} tE t. 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