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0161 PARKER ROAD - Health
161 .Parker,Ro id • . . A = 176 - 016 - 001 W,.Barestable I I -toqrvzpvoqw ARNSTABLE {/ LO ATION lovN7"Zy c. r¢ y SEWAGE # VILLAGE tAj N sra 0 ASSESSOR'S MAP & LOT�A" INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY pOD LEACHING FACILITY:(type) (size) l �x r NO. OF BEDROOMS :S PRIVATE WELL OR PUBLIC WATER (,Ve BUILDER OR OWNER VoU0, jd- S 0A) DATE PERMIT ISSUED: S DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No . 1 ,`N/ "\� rv.�' �3 .,. Z 1 .�'� ` �����` i �� Commonwealth of Massachusetts I � — - 00 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 Parker Road ' Property Address I Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. City/Town State Zip Code Date of Inspection M �a uw Inspection results must be submitted on this form. Inspection forms may not be altered in any Xj 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 cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Lane Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 8/15/2018 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 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owners Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.. Comments: The dwelling located at 161 Parker Rd West Barnstable is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a precast leach pit. The system was found to be in proper working condition at the time of inspection. 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.doc•rev.6/16 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 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):. C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 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 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 117 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. Citylrown 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every Nest Barnstable Ma. 02668 8/15/2018 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 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 gpd t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. Cityrrown 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 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-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 141, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 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: 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joints ok, no leaks , vented through roof Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 4" 15ins.doc•rev.6/16 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 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 3" 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 10" 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.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. CitylTown 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1x1000 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was found to have 1' standing water with a stain line 2' higher. 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.doc•rev.6116 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 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form l' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately p ex 0 Z 3 13( _ 13Z �3 33 /,�N 13y t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form o� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owner's Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. Cityrrown 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: 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts J Title 5 Official Inspection Form r4 Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 161 Parker Road Property Address Havana Moss Owner Owners Name information is required for every West Barnstable Ma. 02668 8/15/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection S.Immary 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 F TC IC F AN Iterstol"t S9ft-emotid Order ft. 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Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 Brun City/Town State Zip Code (508)428-4028 S 14454 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 i ❑ Needs Further Evaluation by the Local Approving Authority t 7 ` �. 4/09/2008 wz. , Inspector's Signature Date - r" �f The system inspector shall submit a copy of this inspection report to the Approving Authority`(1oard of Health or DEP)within 30 days of completing this inspection. If the system is share"dsystem or has a design flow of 10,000 gpd or greater, the inspector and the system ownE r shall submit,ffie 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. 161 Parker Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c,M 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every 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: ® 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 septic system is in proper working order at the present time. 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. 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 tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board.of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 161 Parker Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is.within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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. 161 Parker Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 161 Parker Rd.•0310E Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 161 Parker Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid; depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 161 Parker Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection 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 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well Water 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 4/09/2008 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: Last date of occupancy/use: Date Other(describe): 161 Parker Rd.•03/OE Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Parker Road M Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 161 Parker Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 161 Parker Road M Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 16" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20'+ feet Comments (on condition of joints, venting, evidence.of leakage, etc.): Joints appear tight.No evidence od Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gallon Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle 24 V. Scum thickness Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 161 Parker Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 i F Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appear to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 161 Parker Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 r' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a` 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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 is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 161 Parker Rd.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: 1-1000 gl. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Water was 48"to invert pipe at time of inspection.Stain line is 42 to invert. 161 Parker Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 to Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 161 Parker Road Property Address Heidi Moss Owner Owner's Name j information is required for 1N.Barnstable Ma. 02668 4/09/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 161 Parker Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Map - Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out J J' J In A R K'y i i rJ J i ` � f J . i r J i t rJ i J J J 1, rI 1 J '1 fJ t f l' 'f 4 / \ J / \` f f J 0 J 0 ez _ J .. 0 20 Feet -- Set Scale 1" = 20 I Aerial Photos (`nnurinhf 7nnS_7nm Tn;.,�of R7r .f.hj0 AAA 611 rinh}c rocnn., 1 http://w,Aw.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=,176016001&... 4/11/2008 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 161 Parker Road Property Address Heidi Moss Owner Owner's Name information is required for W.Bamstable Ma. 02668 4/09/2008 every 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: Bottom of LP 30' 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: As-Built Card ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 Annual ranges of groundwater elevations. 161 Parker Rd.•03/03 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable Regulatory Services snxNsrwaLe Thomas F. Geiler,Director 39- Public Health.Division 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 not 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. �� � r are �� �. "t. ,;a �• No.<9�S :C?a: S a111,J L1 , 1164 Fas. ........... THE COMMONWEALTH OF MASSACHUSETTS ()01 BOARD OF HEALTH ° N'�'.-----.OF.... 1Z.ir'.1e�..•----------- ......................... ► Apptiration for Diovo,ittl orkli Tonstrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys at: Q� � ' ..... Ie.!__ _....-=••_=-== =--�Ok'--t_.... '� 1.r °.1 .7 L7 L� CEs u no ?Z ..!/►�`f9- ----.... _......._ - - oration d e or Lot No. C� �m f�el f ... : ._ ... � ..------•-••--------_--- •-•-•-••••-.-•••••............•----•....... ...... \..._.. ..._.............. - - ----• Owner Address W Installer Address Z.'78J 715'® Type of Building 3 Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................... .....Expansion Attic'- Garbage Grinder.-{—j-- ►- Other—T e of Building Z�s No. of persons ............. Shower — Cafeteri G4 YP g P fir— a-(--}--- 04 Other fixtures ....... ............................................ --.._..._gallons per person a day. Total clail flow........�s3..!..............dons. W Design Flow................•---- - ga P P P�' );• � Y WSeptic Tank—Liquid cap, L. ?'gallons Length._9... ___ Width._ _.�./6��Diameter................ Depth..-- _........ x Disposal Trench—No - Width.................... Total Length.............;...... Total leaching area....................sq. ft. Seepage Pit No.....A............. iameter......&..... Depth below inlet....Co............ Total leachingarea..,S-n.a.sq. ft. Z Other Distribution box ( Dosing nk P 2'9��— j Percolation Test Results Performed by... J. 2 f 11 c� l .. Date_.. { Test Pit No. L. '*'-'A..minutes per inch Depth of Test Pit-_/-E�v`� Depth to ground water........ F...`f.. GL, Test Pit.No. 2...=L�..mmutes per inch Depth of Test Pit... _�.�_.._. Depth to ground water.....0......_. O Description of Soil......._1'Y? ..__ ... ._. ... _._..`-�.. �Q _. ..... '� •1^�-�' uc--•--... ............................ •-•-- 1 ........��/ 1...c��........ .` 7......................... •----...--••------W .................. VNature of Repairs or Alterations—Answer when applicable.........................:..............................................I....................... -------------------•---•--•---...............---•-•--------•-•-----•----------------...-•-------..............-----•-----•--...--•-••-•----.........------•--------....---...............•-•-••••-•..... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLE 5 of the State Sanitary Code—The undeUlgnedher agrees not to place the system in operation until a Certificate of Compliance has been ed b e boh. �- . g �S � - Da Application Approved B �- � �.......................... J.9 Date Application Disapproved for the following reasons:.............................................................................................................. .............................•• .......... .................................................... Date — Permit No.......... Issued................................:. Date r � r �,,�. +. M .:w-1;,` fez, 1 `•��-� �.�••y J t a r Y 4,, r No. ..... 1..,._..:4' _ FInc _ THE COMMONWEALTH OF MASSACHUSETTS _ �, !N BOARD OF HEALTH Appliration for-Disposal Works Tonstrnr#'ton Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage.Disposal System at: � � � �e �•: • _ Q�- l ;..... � _ '_}!� ��' /t.. .�.TCam.. �..7........ O r�.............CavN;R,Y �✓.�x-,� �s•~ - --Location-Address or Lot No. .. =- ......... .... ? �: '► -- ------- -•---.....----•=------ ----........... ......--•--._..........._....---•---.......... Owner Address (� f Installer Address 2.7a 750 Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......... ------ .....................Expansion Atticl�_r Garbage Grinder-E--j---*- 4 Other—T e of Building a Other—Type g _�_._ :S_� ..._. No. of persons_____.__............. Showerg,.�--•-j Cafeteri. (----- -.. t, Other fixtures ...... --------------•---•------......__•---------------•--•------•-----------------•---•----------•-•....... •-•------------------- W Design`Flow...................�:?..��•..__.....gallons per person pe� day. Total daily flow...._.._-2�..d...............gallons. WSeptic Tank—Liquid cap t�a!``'_�?gallons Length-.8...-�--- Width_.�1__U'.�Diameter..._._-..._...... Depth..'f....... x Disposal Trench—No_e_____ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......I............. iameter......Z.4G..... Depth below inlet....(a........... Total leaching area...—S—Z.sq. ft. Z Other Distribution box (� Dosing a ) p 2� .� r� �a Percolation Test Results Performed by... . ._:,.. •T ......... Date.....! u--7,..�........... ;r ' ,,.a Test Pit No. L__�..��.+..mmutes per inch Depth of Test Pit__/_g.��� Depth to ground water..... � Test Pit No. 2___!!�Z' .minutes per inch Depth of Test Pit.... Depth to ground water:___. .__._... _. ---------------- - -......... ---------•------ - Description of Soil..:....�'?'?__ _ - ..� ......__..... `--" e 4 �'' ® ,ll�,/.. 1. .. ........................ ...... *. .:.......................: ............. w ---------------------------%----------------------...----------:.......-----------....---------•----.._...----=----_.. U Nature of Repairs or Alterations—Answer when applicable................. ................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been -i sued by •he board of health. L ��-4 Signed._ �-------- �, _ .._.... D r/ Application Approved By � �r`.z..c -- �A mat —`y '% c'`JDate ' Application Disapproved for the following reasons:--------•---------------------•-----------..._......-----------•--------------------------....._---•------_..._ --•-••-•...................•-----•--_•---•----------------------•-----.......----...---...-•--••---••....,-•-----•---.._......-----------.....------.....................-------...................._.... Date PermitNo. �~� - r ....%� -_.__. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS „ . T _'//BOARD OF HEALTH .................................OF.... .;Z '--V..'.............................. rrtif iratr of Tontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (k<10'r Repaired ( ) by...........................................................-.................:...----••-------------._.....----•-.-•--.:......._•-------••-----...........--.•e-----------•-----.............•--- Installer GJ L 1�• G�v v Ni.2 1' at.... - -- ...............•--------------------- - r w' r�"` < •----��-----�---------------- � has been installed in accordance with the provisions of TITI' _5 of The State Sanitary Code-as described in the application for Disposal Works Construction Permit No... A>_-_..... dated_--..___•�.r._�� � -7,- ��'•..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Y DATE._..-----�f--•-•_:..... ... Inspector. ... s THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH NO......................... le 1.. ........... Disposal Works Tonstrnrtion rrntit Permission is he ebygranted........................_sf..: ••----------------------- -- _.�to Construct, or lir ) a In vidual Sewage Disposa stem at No _L --- .. tree 1 as shown on the application for Disposal ��'orls Construction Permit N �' --:_ Dated.... l �.:2.y��`: s....... w did r I �....._ Board of Health DATE_..-----..�T' -------- ........................................................ ` i 7 „ CRAIG A. SHORT, P.E. 14 TORY LANE, DENNIS, MASSACHUSETTS 02638 OFF.(508)385-6530 RES.(508)385-9513 APRIL 23, 1991 Mr. Thomas McKeon Health Dir. 367' Main Street Hyannis, Mass . 02601 RE: CERTIFICATE OF COMPLIANCE 165 Parker Road WEST BARNSTABLE DEP SE 3- 1209 Dear Tom 3 This is to certify that I inspected the excavation for the leaching pit at Lot 6 Parker Road. The unsuitable material was removed 10 feet all around the leach pit . Although I was not called to make the final inspection I have plotted the the distances to the various components as provided by the . owner and shown on the attached plan. Based on the above and that Mr. Donaldson' s stated he has had no problem with it's functioning, I certify that the system meets the intent of my design and complies with Tilte 5. If you have any questions on this matter please contact me . Sincerely ' U C Cr ig R. Short, P .E. encl . V -� Professional Cival Engineer • Custom Designer • Builder Member ASCE 0 MALSCE Log Number: - 13o,ttle # , D064, Date: 7.115.185 BAI? BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE V BARNSTABLE, MASSACHUSETTS 02630 Asa DRINKING WATER LABORATORY ANALYSIS PHONE: 362-2311 EXT. 331 Client: Rob Donnelson Collector: Mike Leary . Mailing Address: P.O. Box 841 Affiliation: well Driller Mashpee, MA 02649 : Time & Date of Collection: 7/10/85, 2:30 p.m. Telephone: Type of Supply: well water Sample Location: Church St. Well Depth: Barnstable Date of Analysis: p.m. PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 ml 0 0 H 5.7 Conductivity (micromhos/cm) 85. 500.0 Iron ( m) 3.2 '0.3 Nitrate-Nitrogen ( m) <0.04 10.0 Sodium ( m) - 20.0 I . Water sample meets the recommended limits for drinking of all above tested parameters. II . xx Based only on results of the parameters tested for this sample, the water is suitable for drinking but may present the problems checked below: A. Water sample has higher than average levels of Nitrate. Future monitoring is recommended (2-3 times per year) to establish any upward trends. B. The low pH of the water may shorten the useful life of the house's plumbing. C. xx Water may present aesthetic problems (taste, odor, staining) due to high iron D. Water sample has high levels of sodium. Persons on low sodium diets should consult their doctor. III. Due to one or more of the reasons checked below, this water sample is unfit for human consumption: A. High Bacteria B. High Nitrates The Rnrnstable County Health and Environmental REMARKS: s.as ' , Department shall not endorse any one interpretations or conclusions made an by Y `w else concerning these results without written consent, CC: Barnstable Bard of Health / CC: M" e Leary Well Drilling 117185 oratory rector s C,7 0/ No. ..... FR$..... ...-.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................OF....:..Z.......................................................................... Appliratinn -fur Jinvunttl Works Tnnitrnrtinn Vrrntit Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: P 01-1F---.. .......................................... Lo ion•Address o Lot No. xy i OOv Address Installer Address Q Type of Building Size Lot----------------------------Sq. feet Dw - g— .Expansion Attic (!Jd) Garbage Grinder No. of Bedrooms------------------------------------------- p, Other—Type of Building ----------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) ag Other fixtures ...................................................... .........................-----------------------.--- -�4 --------------�`---.----- Q W Desi n Flow............................................gallons per person per day. Total dailyflow____._..._.......___ .._ __--_- ..._.... WSeptic Tank 1 Liquid capacitv_LZ►QQ.gallons t,Length................ Width................ Diameter__--- .----- Depth---gallons. x Disposal Trench—No_ --------------------- Width------oF_----__-_ Total Length........-2.Q----- Total leaching area...... ---sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below 'nlet_ ________...._..... Total leaching area--;_-----.---__-..sq. ft. Z Other Distribu_ion box (<) Dosing tank ( ) ;, 4- ,5-`- 7 J`— a Percolation Test Results Performed by------- -------------------------------•---•--•--•---------------•-------- Date..................................... Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-----------.---.__.___-- rZ4 Test Pit No. 2................minutesper inch Depth of Test.Pit.................... Depth to ground water........................ O Description of Soil---------:--Ca� 1 '� ����'---------"-- �� �� ... -'` - ---------- U •----------- ................... --------•------------- ------ W ---•----•---------------------------------------------------------------- � __ _ _ ______ _____ UA Nature of Repairs or Alterations—Answer when applicable................................................................... -------------- .............................. -------------------------------------------------•------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions cf Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued by the be d of health. Signed------- --- ---,----•-----•--------------------------- Z Application Approved B ��-- - - ---C--- ...... ...... 7 Date Date Application Disapproved for the following reaso s:-----------------------------------------------------•-------------------------------------•------------------- --•---•..............................:....•-----......-----------------...---•---•-•--------------------.-----------------------•--......•---------------........................--------••---------•... Date PermitNo......................................................... Issued........................................................ Date / No.. .... ..... , FEE.......1.. ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _. -- ..OF........ ..�............... .......... Appliration -for Uhipuna1 Workii Tnn,itrnrtinn Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at ------ e --------�-t J.ecat�on-, d res or t No Wn r Adddress --- Address W ANIS'�' ���, Q Type of Buildi Size Lot---------_•___----_-.--__.?q.Wet U DwelNO. of Bedrooms--------------------------------------------Expansion Attic (Ili) Garbage Grinder fid) `I Other—Type of Building - __-____ No, of persons____________________________ Showers — Cafeteria dOther fixtures ----------------------------------------------------- ...............................................................--_------------------------- Design Flow_____________ .......................gallons per person per day. Total daily flow____-___-__--_.___-_•-��_.--.--.---gallons. W USeptic Tank L Liquid capacitv// ...gallons Length---------------- Width.------..------- Diameter---------------- Depth.__._-_.-_-_.-. xDisposal Trench—No- -------------_------- Width---- --------- Total Length------&4....... Total leaching area.......*V.....sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below-inlet___ ___- __ � al-leaching area----------------_.sq. ft. Z Other Distribution box (�) Dosing tank a Percolation Test Results Performed bY------- ------- ---------------------------------------------------- Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit-.-_____________-_- Depth to ground water-_._-.-__-_---_.--_- �Xq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth/to ground water-------.---------------- C.' .._._ O Description of Soil----------- 0..-.----�•-------------"". G"�t-,,•c. -- --- !/_. V ----------•----•----------------- -------------------------- --------... -- - ,_ r - --,�-- •-o-- -------- it - , _ ----------------------------------------------'--------- W --------------- j` = : _ ------------- ---------------- U Nature of Repairs or Alterations—Answer when applicable icable.............._.._-__:_-__-__--_-_-�--___..-______-____-__-------._.._-_.._.______--- ----------------------------- ---------------------------------------------------------------------- ----- ---------------------------------------------------- -------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System iii accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by th�ard of health. /"Signed . ............... --•---------------•-•----•-- ... Application Approved BY------- - 4 .. -----••-• ••-- - ------ ------- n Date Application Disapproved for the following reasons:..............................................................................:................................ ---•--•---------------------•-------------••••------••--------------'------------•----------•-•-•--•••-----------------•-------•--•-'-•---•---•--... --------------------------------------........... Date PermitNo.......................•-------------------------------- Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL � Q�r-a �...............OF..........Z�� ................. .......--...........:.... %:.rrtifiratr of TIOntpliaurr THIS.I:- TO CERTIF• That the Indi Sewage sppsal System constructed ( or Repaired ( ) by---.. a ....` ------ --- . ..'" f �r� Installer at. 1_.*_:=......... 1._L _._ -t. t ..'_-� -✓ ••----------------- -•----------------••---•--'•------•-•-------••---•-•---- has been installed in accordance with the provisions of Ar 'c, XI of The State Sanitary Cod( as described in the application for Disposal Works Construction Permit No....(k ------__2.............. dated___ 4�-_- k.�_,. )_ 7.6__:_. THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUE© AS A GdARANTEE THAT TIME SYSTEM WILL FUNCTIO SATISFACTORY. DATE .. ------ ---------- Inspector....- - ........................................ THE COMMONWEALTH OF MASSAC SETTS BOARD OF EALTH Tu OF............. . .....G!�t.-s-- --..................................... No......................-• FEE----- -•--- Bi>t-upntittl Workii Cronitrnrti it Permission is h reb ranted____._.., rr`- „� Y g CAL : •-•-•------------------- to Construc ( or Rep if j( ) a>2 Indivi a age Disp�al�System � at )^ Street as shown on the application for Disposal Works Construction Permit No.-_-_-_ z- ------ ---- Dated----��•F�1�-�-- 4 �f ---------_ -__ ._i.yt �... .. .. . . ......... Board of HealtFi _ DATE------- = !`� _�� -�--._ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 00, 9 _ h R� r N / 'J)Q OCJ� �j9 j (Y) O / N lf) / Q00 CD Oro o Ct' N L N _ N o ti 1 ^i w O N J r. ,.b.... - _, ,`� FOB ff�".tell /""yS � . West Barnstable Builders Inc. � ® �� c � SHEET NO. / OF NCALCULATED BY �� DATE "" — 1170 RT. 6A • West Barnstable, MA 02668-1124 . ,, . >.�,T.�m,.�..�. �...... ..,,..._.,..,..w„<,,.,.�,...... CHECKED B V D AT E . (( // SCALE 'i [ E I r I .; .4 ( j I i < , __ _._. .. .. 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