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I Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Point Hill Road M !:n Property Address !V Ann Burchill Owner Owner's Name • information is required for every West Barnstable ✓ Ma 02668 2-21-17 page. City/Town State Zip Code Date of Inspection CJ1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ��•� �o2aZ� on the computer, f� use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI13747 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 2-21-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original shou!d 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: System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 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: System,was in working order at time of inspection. The pipes between the tank and d-box and between the d-box and pit are partially crushed but are still in working at this time. Pipes may need to be replaced in the future. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. City[Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. Cityfrown 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 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments �M 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is West Barnstable Ma 02668 2-21-17 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the:Department. t5ins•3113 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 �M 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. CitylTown 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): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. CityTTown 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 ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gp ))� Detail: *"WELL WATER" Sump pump? ❑ Yes ® No Last date of occupancy: Nov 15thDate Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 i c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Last pumped 3 years ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 120'well to SAS feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' 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: 1000gallons Sludge depth: 5" t5ins-3/13 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 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. CityrFown 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 31" Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? 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 was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G"M 100 Point Hill Road Property Address P Y Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up or carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (2)6x6 II ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Pit 1 was dry with no high staining and pit 2 was dry with a stain line 1' from floor of pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 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: NA 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 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 A1.14' 131.37` A2•201" 152-37'9" HOUSE 30'6" B3-4a` A4-01' W.-:B�+0' y . B C BARN C3 3. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. CityrTown 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 9 high round water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2-23-1978 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Point Hill Road Property Address Ann Burchill Owner Owner's Name information is required for every West Barnstable Ma 02668 2-21-17 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E 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 Message Page 1 of 1 Miorandi, Donna From: Miorandi, Donna Sent: Tuesday, June 09, 2015 2:09 PM To: 'joe.cosgrove@raveis.com' Subject: 100 Point Hill Road, West Barnstable Good afternoon Mr. Cosgrove: Just an FYI that your listing for this address is a problem. It was only permitted as a 3 bedroom septic system and is only good for that amount of bedrooms. This was installed in 1978. They never got a permit to go to 4 bedrooms never mind 7 bedrooms. The state law only allows one bedroom per 10,000 sq. ft. Thereby only 3 bedrooms allowed due to being on a well. They will never be allowed to have 7 bedrooms. Donna Z. Miorandi, R.S. Town of Barnstable Health Inspector 508-862-4644 6/9/2015 Commonwealth of Massachusetts Owner Title 5 Official Inspection- Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 1.00_Point Hill Road, W. Barnstable, Ma. Property Address Ann Birchill Owner's Name P. O. Box 677, W. Barnstable _ _. .-_ MA 02668 May 11, 2011 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms / on the computer, �IV1n use only the tab 1. Inspector. �y key to move your cursor-do not Dan A. Speakman use the return key'... Name of Inspector - Read-Er; - Company Name 15 Speak Way--- - i Company Address North Harwich Cityrrown State Zip Code 508-432-5565 SI -637 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: x❑ Passes ❑ Conditionally Passes ❑ Fails a ❑ Needs Further Evaluation by the Local Approving Authority - r _ _ 14, 2011 InspectorsSignature Date -' z iIj 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 ajshared 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 L4 s/ I r i r Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 100 Point Hill Road,_W. Barnstable,Ma _ - Property Address Ann Birchill Owner's Name P._O. Box 677, W. Barnstable MA 02668 May 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: 2-te 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: B) System Conditionally Passes: ,,j ❑ 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): Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 t5ins•11110 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 100 Point Hill Road, W. Barnstable, Ma. - Property Address Ann Birchill Owner's Name P. O_Box 677, W_Barnstable MA- __ 02668 May_1-1, 2011 CityrTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): gi ❑ 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: jAJ ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 100 Point Hill Road, W. Barnstable,_Ma. Property Address Ann Birchill Owner's Name P. O. Box 677,_W._Barnstable MA__ 0266 8 May 11, 2011 _ -- -- CitylT-own State Zip Code Date of Inspection S. Certification (cont) 1 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 ❑ 2/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Ld" Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ �% Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 / � . . . , Commonwealth of Massachusetts Titl^�~~��N�� �� ��^���~�����N N��������°=������ ����N°0�� e �� ���NNN��0��N Nmm�~��~*�~�m�~wm Form »wm»'informa*nnis Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 100 Point Hill Road. Barnstable, yWg' Property Address Ann \ ...... — ' - ' — --- ----- --- — Owner's Name P. [>. Box 677, VKBarnsbab|e K8A 02668_ _ May 11`2011---------_GityrTown State Zip Code Date __ _ of Inspection B. Certification (cont.) Yes No _' ~� Required punnpingmore than 4 times in the last year NOT due todoggedor LJ Le�� obstructed pipa(o). Number of times pumped: __---. El --~°/ Any portion of the SAS, cesspool or privy is below high ground water elevation. �r^ Any porbonof cesspool or privy isvvithin1DO feet ofaeu�ooe water supply nr El "� tributary boa surface water supply. -`~/ Any portion ofa cesspool nr privy \o within o Zone 1 ofa public well. "� c�^ Any portion of a cesspool or privy is within 50 feet of a private water supply well. [l IT"" Any portion or privy is |ame than 10O feet but greater than 5Ufeet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed atmQEPcertified laboratory, for fecal cmDfmrmmbacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen |m equal tmPr less than 6ppnn, provided that nm other failure criteria are triggered. Acopy of the analysis and chain mf custody must be attached tm this 0onmn.] [l [a-,**' a~/ The system iae cesspool serving o facility with adesign flow of2UO0gpd- � � 10.000gpd. � --~~' The systemmfa��. | have dehernninadthat one orrnoneof the above failure � [] �� chhodm exist aedescribed in 310 CK0R 15.303. therefore the system fails. The system owner should contact the Board of Health tn determine what will be necessary hn correct the failure. E) Large Systems: To bwcmmmi dermdmlmrg mm the mymtemmmnomtserve mfmcUitym/ithm design f|ovxof10,000gpd tP15'0Q0 gpd' ^J �A For large aystennn, you must indicate either^yeo^ or"no" to each of the following, in addition to the questions in Section D. Yes No | [l [l the nyotarn is within 400 feet ofo surface drinking water supply � El El the system is within 2OO feet ofatributary to surface drinking water supply the ayotamnio located ina nitrogen sensitive area (Interim VVeUheadProtection El �� Area— VVPA) or a mapped Zone 11 of public water supply well f Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 100 Point Hill Road, W. Barnstable,Ma_ ___,___--.-. Property Address Ann Birchill Owner's Name P,_0. Box 677 W. Barnstable MA 02668 May 11,2011 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 El ET"" Pumping information was provided by the owner, occupant, or Board of Health ❑ E�-� 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? ❑ L?r 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? p� ❑ 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 (actual): y Number of bedrooms (design): - ) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): - 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 l5ins•11110 I Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page- 100 Point Hill Road. W. Barnstable, Ma. __.-.---. Property Address Ann Birchill Owner's Name P. 0._B_ox 077, W_Barnstable _ MA 02668 May 11,_2011 City/Town State Zip Code Date of Inspection D. system Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes 9"No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes C?-No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes P--"No Water meter readings, if available (last 2 years usage (gpd)): �L� Detail: Sump pump? ❑ Yes Et"No Last date of occupancy: / Date Commercial/Industrial Flow Conditions: A) Type of Establishment: Design flow(based on 310 CMR 15.203): G__. ---.__. —_ allons 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 100 Point Hill Road, W. Barnstable, Ma. .............. .......... Property Address Ann Birchill .......... Owner's Name P. O. Box 677, W. Barnstable MA 02668 May 11, 2011.1 city own State Zip Code Date of Inspection D. System Information (cont.) /J/4 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 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 F1 Overflow cesspool 11 Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) El 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 0 Tight tank. Attach a copy of the DEP approval. El Other (describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 100 Point Hill Road,.W. Barnstable, Ma, Property Address Ann Birchill Owner's Name P. O. Box 677,.W._Barnstable MA 02668 May 11 2011 __.._ 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: Were sewage odors detected when arriving at the site? ❑ Yes D"N'o 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 suctionline: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: a-c-crete ❑ metal ❑ fiberglass Elpolyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No lad?0 Dimensions: � f Sludge depth'. 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 100 Point Hill Road, W. Barnstable, Ma, Property Address Ann Birchill Owner's Name P. 0. Box 677, W. Barnstable MA _ 02668 May_11 2011 _ 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 -- - t Scum thickness Distance from top of scum to top of outlet tee or baffle f Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? _S rJ 2 E4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): S__770,0E Czyo_o�o .Go­l4 i 7-cc"J,_. P-2EcA.S Grease Trap (locate on site plan): /U �t 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments required for every page 100 Point Hill Road, W._Barnstable, Ma. ----------- Property Address Ann Birchill Owners Name P. 0. Box 677 W. Barnstable MA 02668 May 1.1, 2011 cityr own 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): �U l'1 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 t5ins•11110 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 100 Point Hill Road, W. Barnstable Ma Property Address Ann Birchill .- - -- Owner's Name P. 0. Box 677 W. Barnstable _.__ MA 02668 May 11,_2011 City(rown 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 O 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.): _�-__r3_o X__�_s..�--� -G_o—�--�•_.�i�rc �J_.-~ �� -o u T�ETS — w a_ _ ....................... Pump Chamber (locate on site plan): aU Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 100 Point Hill Road, W. Barnstable,_Ma._ Property Address Ann Birchill _ __ _... .._....._. Owner's Name P. O. Box 677,W. Barnstable MA 02668. May 11, 2011 Gityfrown 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: -- - ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 100 Point Hill Road, W.. Barnstable, Ma_ Property Address Ann Birchill - Owner's Name P. 0, Box 677, W. Barnstable MA 02668_ May 11, 2011 ------ CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): ;j A Materials of construction: -" Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Owner information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 100 Point Hill Road, W. Barnstable Ma. - Property Address Ann Birchill _ Owner's Name P,._0. Box 677, W. Barnstable MA 02668 May 1.1., 2011 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 731 --- - 37 3p S 9 So' 0 0 Y � 2 1 1 I 3 � G � l i � p 63 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of 17 t5ins•11/10 r Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments required for every page. 100 Point Hill Road, W. Barnstable, Ma. Property Address Ann Birchill Owner's Name P. O. Box 677, W. Barnstable _ MA 02668 May 1-1,2011__-_ .__. 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: .fee_. ----_ - t 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 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r Commonwealth of Massachusetts Owner Title 5 Official Inspection Form information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments required for every page. 100 Point-Hill Road, W. Barnstable Ma. Property Address Ann Birchill - Owner's Name P. O. Box 677, W_Barnstable MA 02668 May 11,_2011 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist B-11`Inspection Summary: A, B, C, D, or E checked C'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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �1 F COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 100 PAINT HILL RD W. BARNSTABLE a Name of Owner JOHN WEISS Address of Owner: 167 OLD MAIN ST.S.YARMOUTH MA.02664 Date of Inspection: 6/16/99 Win Name of Inspector:(Please Print)JOHN GRACI C I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) J V n� 99 2 3 19 _ ►� Company Name: n/a to T0Kw0Fg v�°�" Mailing Address: n/a N�1HDFp/-'4&t Telephone Number: n/a f'*a A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection Is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:6/17/99 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2198 Page 1 of 11 L , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 PAINT HILL RD W.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n1a 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n1a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether,or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed distributior box is levelled or replaced n/a The system required pumping more than four 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 revised 9/2/98 Page 2 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 PAINT HILL RD W.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16199 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n(a_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 PAINT HILL RD W.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an 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%2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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 I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 100 PAINT HILL RD W.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16/99 Check if the following have been done:You must indicate either"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 None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised.9/2/98 Page 5 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 100 PAINT HILL RD W.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16199 FLOW CONDITIONS RESIDENTIAL: Design flow:J40.g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 444 Number of current residents:11 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):JLQ Seasonal use(yes or no):JLO Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: 111/99 COMMERCIAL/INDUSTRIAL Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):JM Industrial Waste Holding Tank present:(yes-or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) BLa Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: DLa System pumped as part of inspection:(yes or no):NO If yes,volume pumped nLa. gallons Reason for pumping: Wa TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 15 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 PAINT HILL RD W.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16/99 BUILDING SEWER: (Locate on site plan) Depth below grade: V 6" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No nta Dimensions: L B'6"H 5'7"W 4'10" Sludge depth: X Distance from top of sludge to bottom of outlet tee or baffle: 3 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: nta How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: n& Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:ji& Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: Wa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) D& revised 9/2/98 Page 7 of 11 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 PAINT HILL RD W'.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16/99 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nla Capacity: n& gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:_nLa. Alarm in working order:Yes_No_ NQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 PAINT HILL RD W.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: jVa leaching galleries;number: ji& leaching trenches,number,length: nLa leaching fields,number,dimensions: n& overflow cesspool,number: nLa Alternative system: nLa Name of Technology: _DLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: n& Depth of solids layer: nLa Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: nta Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:nta Dimensions:nLa Depth of solids: Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 PAINT HILL RD W.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a e 0 gc�cn �S m Y? 0 revised 9/2198 Page 10 of 11 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 PAINT HILL RD W.BARNSTABLE Owner: JOHN WEISS Date of Inspection:6/16/99 NRCS Report name: n/a Soil Type: n& Typical depth to groundwater: nla USGS Date website visited: n/a Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL-12+FEET revised 9/2198 Page 11 of 11 Commonwealth of Massachusetts 2 �� Executive Office of Environmental Affairs 7 Department of Environmental Protection WIIIIamm F.Weld - - -- ...._Govemor s.ru«.di.y%EA ®� Davld S.Struhs SUBSURFACE SEWAGE DISPOSAL SYSTEM INFORMATION FORM Commhmioner PART A CERTIFICATION .d Property Address: 100 POINT HILL ROAD, W.BARNSTABLE Address of Owner: GROVE BANK Date of Inspection: FEBRUARY 22, 1996 (if different) 1330 BOYLSTON ST. Name of Inspector: LAMES A.ORPHANOS CHESTNUT HILL.MA 02167 Company Name,Address and Telephone number: CERTIFIED INSPECTION ASSOCIATES 47 CAMERON ROAD,N.FALMOUTH,MA 02556 (508) 564-5653 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signatur . Date: FEBRUARY 22. 1996 The system Inspecto sha submit a copy of this inspection report to the Approving Authority within(30) days of completing this inspection. If the s inis 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined (Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)SWI049 • Telephone(617)292-5500 Printed ore Rlq-dW Papa v r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r CERTIFICATION(continued) Property Address: 100 POINT HELL ROAD Owner: GROVE BANK Date of Inspection: FEBRUARY 22. 1996 B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with the approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection(with the approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health,safety and the environment.. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system.has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50'of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a -private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is outlined below. The Board of Health should be contacted to determine what will be necessary to correct the failure.. Backup of sewage into the facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or the surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 POINT HILL ROAD Owner: GROVE BANK Date of Inspection: FEBRUARY 22, 1996 D] SYSTEM FANS (continued): Static liquid level it the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pu_-nped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable;attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAIlS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 1G,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 4D0 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 lI of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 100 POINT HILL ROAD Owner: GROVE BANK Date of Inspection: FEBRUARY 22. 1996 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of SCUM. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants„if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 100 POINT HILL ROAD Owner: GROVE BANK Date of Inspection: FEBRUARY 22, 1996 FLOW CONDITIONS RESIDENTIAL: Design flow:440 gallons Number of bedrooms:4 Number of current residents:-0 Garbage grinder(yes or no): NO Laundry connected to system (yes or no): YES Seasonal use (yes or no): NO Water meter readings,if available: HOME IS SERVED BY A PRIVATE WELL. Last date of occupancy: DECEMBER 1995. COMMERCIAL/INDUSTRIAL: N/A Type of establishment: Design flow:---gallons/day Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings,if available: Last date of occupancy OTHER: (Describe) Last date of occupancy:: GENERAL INFORMATION PUMPING RECORDS and source of information: THE SYSTEM HAS NOT BEEN PUMPED DURING 1995 System pumped as part of inspection: (yes or no) NO If yes,volume pumped: gallons 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) Other(explain) APPROXIMATE AGE of all components,date installed(if known) and source of information: THE HOME WAS CONSTRUCTED IN 1980 DISPOSAL WORKS CONSTRUCTION PERMIT#84-475 FOR A REPAIR IS ON FILE AT THE BOARD OF HEALTH. Sewage odors detected when arriving at the site: (yes or no) NO revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 100 POINT HILL ROAD Owner: GROVE BANK Date of Inspection: FEBRUARY 22. 1996 SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete metal FRP other(explain) Dimensions: 5'WIDE X 8'LONG X 50" DEEP(BELOW INVERT) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 18" Distance from bottom of scum to bottom of outlet tee or baffle: 6" Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) LIQUID LEVEL IS 40".HOWEVER THERE IS NO INDICATION OF LEAKAGE. LOSS APPEARS TO BE FROM EVAPORATION AS A RESULT OF NON-USE FOR TWO MONTHS. PLASTIC INLET TEE AND CONCRETE OUTLET BAFFLE ARE IN PLACE AND IN GOOD CONDITION. NO ADVERSE INDICATORS. NO RECOMMENDATIONS. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction: concrete metal FRO 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: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) (revised 8/15/95) 6 . - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Property Address: 100 POINT HELL ROAD SYSTEM INFORMATION(continued) Owner: GROVE BANK Date of Inspection: FEBRUARY 22, 1996 TIGHT OR HOLDING TANK: N/A (locate on site plan) Depth below grade: Material of construction: concrete metal FRP other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: X_ (locate on site plan) Depth of liquid level above outlet invert: 0" (STATIC) Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) BOX IS LEVEL: FLOW IS EOUAL TO BOTH LEACHING PITS NO ADVERSE INDICATORS• NO RECOMMENDATIONS PUMP CHAMBER: N/A (locate on site plan) Pumps in working order: (yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C SYSTEM INFORMATION (continued) Property Address: 100 POINT HILL ROAD Owner: GROVE BANK Date of Inspection: FEBRUARY 22. 1996 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,if possible;excavation not required,but may be approximated by non--intrusive methods) If not determined to be present,explain: Type: X leaching pits,number: TWO PITS IN PARALLEL. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) THE COVER TO PIT#1 WAS FOUND AT A DEPTH OF 14". THE SIZE OF THE PIT IS 6' DIAM.X 6' DEEP(EFFECTIVE) AND IT WAS FOUND TO BE DRY AT THE TIME OF THE INSPECTION. THE BOTTOM OF THE PIT IS APPROXIMATELY 96" BELOW GRADE AND THERE WERE NO ADVERSE INDICATORS AND THEREFORE NO RECOMMENDATIONS.PIT#2 WAS NOT EXPOSED.IN ACCORDANCE WITH THE REGULATIONS.HOWEVER ITS LOCATION WAS DETERMINED BY PROBING AND THE COVER WAS FOUND TO BE 16" BELOW GRADE. PIT#2 IS HIGHER IN ELEVATION THAN PIT#1 AND THERE WERE NO ADVERSE INDICATORS AT THE SURFACE OF THE GROUND.. CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 8/15/95) 8 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 POINT HILL ROAD Owner: GROVE BANK Date of Inspection: FEBRUARY 22, 1996 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I i POINT HILL'ROA[ D WELL IS > 1 00' TO SAS HOME 37' 719" 1811201 91' BARN 5 80' 27' 0" NOT TO SCALE PIT#1 PIT 12 DEPTH TO GROUNDWATER Depth to groundwater: >10 feet method of determination or approximation: ACCORDING TO THE USGS SANDWICH QUADRANGLE (1972)THE PROPERTY IS APPROXIMATELY AT ELEVATION 40 0'ABOVE MEAN SEA LEVEL (MSL)AND NEARBY BARNSTABLE MARSHES ARE APPROXIMATELY 800'DISTANT (revised 8/15/95) 9 i TO. /OF B STABLE LOCATION10b T ' SEWAGE # VILLAGE �ar�n � i[�� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l000 LEACHING FACILITY: type) I (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 u"i '� Cl_ Q4C� �� � 0 G �� �rA SS �1'e a No..................... �J FRic.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF I-I LTH v ® --- ------- ...w......0F........ .................................... ` 1 Appliration for,Disposal Works Tonotrnrtiun Prrutit Application is hereby made f r a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......... ../?�% r: ........................................................ ................................ Locatio -Address ................ ....._._.... .. �d ��Zr...... L� _ . . .....W.X n..�A.g1.�!5�'f � � :�.................................... ----- . W � ner Address a4-r r,,Q. _.....--•--•----••-- •------•.......................................•...........•-•--•----------•-••-------...--••••--- Installer Address Type of Building Size Lot............................Sq. feet C) �., Dwelling—No. of Bedrooms.....3.............. .....Expansion Attic 40) Garbage Grinder 001) p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ---••-------------•----------•--------------•----------------•••------••-------•----. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_------------------ Diameter.................... Depth below inlet....... ........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) k)t// tZj- d�A // // `" Percolation Test Results Performed by.......................................................................... Date......_....�1�O17-- Test Pit No. 1-----2---!-minutes per inch Depth of Test Pit.................... Depth-to ground water........................ �Tq Test Pit No. 2................minutes per inch Depth of Test Pit.............._..... Depth to ground water..._-_.............._... P4 ------ 1.--•--• ---••----------- ---- +----•--- ..1.. Description of Soil---------�?.-... . I'-1 tt ` L--z• cf - - - • . c --------------------------•--------•--------------- ---------------------------••-=------------------------------------------------------------------------ ....._...-------------------------------- 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iisssuueed,by thheeeboard/of health. Signe ..s� fl %/ Date Application Approved BY '? '---•-_. Date Application Disapproved for the following reasons:.............................. ------------------------ ...................................................... ----------------------------------•-•----•-•••--...-----......_.............-------•-••-•-------••••----•-•••••--•--•-•-•-----•-----------•-----•-•--•-------------- ................................... Date PermitNo......................................................... Issued......1-- /•---- ...... ........ Date 00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H LTH .......0 F........{ f Appliratiun for Bhiposai Works Tonstruitiun r.i'mit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• 4.m 1` ................ - :.......--- .................................................. . yet- ;_ - I � "`It3t ?. ................... Lo ......--••-------------•------------ -•-•------...---•••-•----......- . ,4 .............X...&kT ..I..-.r.�.. . ner .•.Address Installer Address VType of Building Size Lot............................Sq. Dwelling—No. of Bdrooms............................................Expansion. Attic = Garbage Grinder (�) a`4 Other-T e of Building No. of persons........................... Showers YP g --------------------•------- P - ( ) — Cafeteria Other fixtures ------------------------------------•----------------------------- ) g ...........gallons per person per day. Total daily flow............................................gallons.W Design Flow--------------------------------- WSeptic Tank—Liquid capacity........____gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length._.................. Total leaching area....................sq. ft. Seepage Pit No._._.---.---_-_-_--- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank __ Date....................................... ~' Percolation Test Results Performed by........................................................ ►� a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit................_.... Depth to ground water........................ a' t i ecripto t O 1 r s n _... ..._.- -_- _ .._...... U ----•----•---•...•-••-.....-----••-----------------------------------------------------------•-••-......------•-----•-----•••-•------•-----•------------•----------.........................--------•- W VNature of Repairs or Alterations—Answer when applicable..........:.......... ................................................--.......=.............................................................--------------..:-----------------------------------------------.._....-••••-•-- Agreement: The undersigned, agrees,"io install the aforedescribed Individual Sewage`Disposal System in accordance with the provisions of iI `I.L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ss dth rd.of ealth. 3/4 I�' Signed ------ . ............(.••-------• --- -----......._.... Date Application Approved BY11 i!F'/�4 -Gf. -� ....---•-- -•--`' Date Application Disapproved for the following reasons:...........................................•-:--...........__...._...._..._._.... ._.........__ ...------•-----------•-----------------•--•--------•----.....---------------------•------------••.........__....._...._....-••----•••---=•---•-----•--------•--•-•----•-••----•--•--------••------•--•••. Date Permit No............................:••-•••......----------•--••_.. Issued . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD ,qF HEALTH Tnrtifitatr of Tompliaurr TO C RTIFY, T�ftt �,Individual Sewage Disposal System constructed ( ) or Repaired ( ) by • ... ..... ... �J�'�-��' ............. . --------- at. _�-- t� p staller P. ._ � ... Gi • C.LL�^ --- has been installed in accordance with the rovisions of ✓ of The State Sani ary Code a d�esgib in the application for Disposal Works Constructs r. Permit No.............. .��................. dated_...q_....Z.._-_%%.. ............ THE 'ISSUANCE OF THIS CERTIFIQ TESHALL NOT B'E CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACT61Y. ` DATE.......................................................... ' ................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF9 HEALTH &77 . FEE Na.... ._.. ..._...- -... !!!j,ark Qlt strnr#ii6n rmi# r Permission i hereby granted_. ..... :�' `-•----------- ---•-----.................. to Cons or R r F,( an i✓ al ey�age Di o Systemor + " at No.� .. j .-- tr.......-A.. -- ...... ....`------..... Street ^� as shown on the application for Disposal Works Construction Perm't/�To____ ____ ________ ated..�,L____�.`. .......... .�.... Bzw`'ws6 ? , u oard of;1lealth DATE...../..... 7g -- --------•••••••• a£d FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �' + ` r �� 1� � / �r..��,.�•Y � ��s o 'l' �'�l I i r 1 i 1 Y TGY"� _�1� 1 f"�i.i17� . 71 • � �� SIN Wir.- y�,��,.� tj Nv {�) ' CA Q` ,- 0 /2 NO &:�AEN34• a 3 4 I!r t 330 IT ! o 46 4 2' OQ 7S•2a Op t , is r`E yFap•ir s, AM-0- P-4 n - 57� -36 'r' -3v s-ZS = ►� _ ,4 50^= 30S I �al L%"�/r(I t �l'.S� ��� /r/r %'�•rh.'Gti'��lk "1�7 � CC�1•�5'kj�.�F✓ s:.._ - I.MR o Miq'l WN lAN'�L 4" T Tim 5 RN•6�• 6�•9B•50 10 pvo I>tJ i M viuM. =cw*4 114-4. gi,,o,o I 1 N G a5.�5 •bfa"-� ; . lo +`-Ire• ��tv FxIX• lo.o {` i �.D tom• �11,'75 � _ �L_._...�._ � f ~j� f f obhla #"( #{=aIN17 f- 2" p a -2I F5twtAa-/ I°118 YOP +T• I ` 'q h �'kAW+ D� ; I�Gt� +IiTI•RY S�R�Ir. r THE COMMONWEALTH OF MASSACHUSETTS s BOAR® OF HEALTH , Appliration for Diipnsal Workii Tonstrnrtinn ramit Application is hereby made for a Permit to C nstruct ( ) or Repair ( ) an Individual Sewage Disposal 0�S...' t j � -� --- .......--- ....................................Q.. S !'J .. .-. ---- t ... --- Location- d e or Lot No. wOwger / dd ess Installer Addre d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.......2w................................Expansion Attic ( ) Garbage Grinder ( ' ) Other—Type of Building ......__.... No. of persons............................ Showers a YP g --------•................................. P ( ) — Cafeteria ( )� A4Other fixtures ------------------ ---.-------------------------------------------------------------------------------•--------.------ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. r Seepage Pit No._---_--_--__-.-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. w , Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 0.4 Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water-__--- ___-_-__-.___-_. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' -------------------------------- ---- -------....--- O Description of Soil----�/={ ................... -//-----�.......' -A14-------- ---................................................ x w UNature of Repairs or Alterations—Answer when applicable................................................................................................ •---------------------------•---------------------------------------------------------......-•----------------•-------------------------------------------------------------------------•-----....------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agtees no to place the system in operation until a Certificate of Compliance has ?beW)iWssuey th oard ohea^1'th?Signed... Date ApplicationApproved By.................................................................................................. --------------------------------------- Date Application Disapproved for the following reasons-.............................................................=............-----------........................ - .......-•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date `No..9.`M/7' ` >` Fic$..�f.o ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. .....OF...................................... Allp iraiiun for orkii Tontrurtion ranfit Application is hereby made for Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: r . Locatio ,P�ydr O ssf * .................. Lot. .} .......... Address � Installer d Type of Builg ` ': Expansion Attic ( ) Garba e Grinde r YP g Size Lot.............................S feet rt°" aDwellintVo. of Bedrooms..__ g ( ) Other—Type of Bui ding ____________________________ No. of persons______..._._._....__...___.. Showers`( ) — Cafeteria ( ) dI Other.fixture's " W Design Flow......................................:.•..gallons per person per day. Total daily flow... ...................... WSeptic Tank—Liquid capacity _.....gall'ons Length_________________ Width................ Diameter_______ ___ Depth_.................. x Disposal Trench No. ............ . Width_... _......_ Total Length.................... Total leaching area----------------I....sq. ft. Seepage P> o p _....... Total leaching( ea.............�...sq. ft. v _ Dlarnleter_________________ _ Depth below inlet_.__._._ Z Other Distnbutiofl•,•;boxf( ) Dosing tank ( ) k*I 0, Percolation Test Results -*'Performed by.. ...........................•__.._.___..._"___ � _ __, ,-� -- Date-:. ................................. Test Pit No. I................minutes per inch Depth of Test.Pit._____......_....... Depth to ground water-__----______-_--.----_. 44 Test Pit No. 2................minutes per..,inch Depth of Test Pit.................... Depth to ground water........................ P4 .................................................. -•-------.........---....--------•--••----•--.................................................... O Description of Soil__- - ---------------C.4A -••-4_...,__54-IV O- V ------------------•------------ -------------------------- •----------------- -,--- W V 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 TITLE S,of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of-Compliance,has b issu by th board f health. t r ++. asSigne r .................. ................................ ApplicationApproved BY •- ------------------------------------•----------f--.--•--•------ -••------- ........................................ Date Application Disapproved f or,the following reasons •-----=---•---------------•----------------•------•-----------------•----------- -••---....-----.... -------•-•-•--------•---------------------•--------•-------••-------•---------------••-------------...._..---------.......------. •--=--................................................................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OP MASSACHUS'ETTS Tr, BOARD OF HEALTH ...................................I......OF (9rditiratr of Toutpfinnrp THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY--•------•--•-•-•---•--------------------------------------------------•-- -•------- -- --------------------------.--------.-_------------.--------------------------•-•-----------•--- .r Installer at.has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F CTION SATISFACTORY. �� f DATE .............................. Inspector..••-- ..---••-----------•---------•-- --•.............•..••--- THE COMMONWEALTH OF MAS,SACHUSETTS BOARD OF HEALTH ...........................................OF.............. /ir... ................ W�iu�roonl urk� �onu�ritrfion �f�erntt� Permission is hereby granted--------166------- --------------------------- to Construct )Gor;Rep ( An Individual Sewage Dis osal System y atNo.-•----•----------•-----------------•---------••-•-T" Street 4 as shown on the application for Disposal Works Construction'Permit No------------------- Pated--_....................................... ... �. ----•-----•--•------- .............. w _ DATE_ BI Board of Health -••---------•----------------------• --- ------------------.--•-- FORM 1255 A. M. SULKIN, INC., BOSTON •''�` '� No. s Fee---- BOARDOF HEALTH TOWN OF BARNSTABLE Zipplicat ion-*r Veil Congtruct ion Permit Application is here y made for a �pei3n it to Constru t ( ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessor s�M.�,and Parcel Owner, — — -- a j Address--------------------- r � e�� ------------------------ Installer — Driller Address Type of Building /' ASSESSORS MAP NO,' `27 Dwelling---- PARCEL---------------------------- PARCEL NO: 0 -41I Other - Type of Building ---------- No. of Persons--------------------------------------____ Type of Well--— — — -- -------- Capacity--- - - -- ——- — - — --— Purpose of Well--- ---------------- Agreement: ,The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. , Signed L - ----- - � -- date Application Approved B 'LL t —r - =-- - —— ¢ ��3//e date Application Disapproved for the following reasons: date Permit No. ---- Issued---- -- - - — ------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) at has been installed in accordance with the provisions of the Town of Barnstable Board of�`Health_Private Well Protection Regulation as described in the application for Well Construction Permit No�'----/---�'; Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- Inspector-------------_______— ---- t I i - =------------ ----N. '' , Fee-------- =---- BOARD OF, HEALTH . l TOWN OF BARN.STABLE Appiicat ion-*rWell ctCongtructiotti3ermit A li���is_here Y O� a P made;f�r e � o—Co nstru t ( ) .Alter (--)-or Repa>�r.( )an Individual Well at: PP � s 'Location, Address + • - - a Assessors Map and Parcel -- �/ Owner y Address -- i /� ✓/ D •�G,� - --------- ---------------, d/ ----------------------- li Installer — Driller Address s Type of Building Dwelling - --- Other -.Type of Building-=---------- - ------ No. of Persons--,-- -------- ---------------------- If ,tee Type of Well---- — — Capacity— Purpose of Well Agreement: I The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by. the Board of Health. o Signed -- -�G -- -- r O 3' 7 7- date Application Approved B -- �-'=------ —` �6 - - ���/���, date Application Disapproved for the following reasons:-------=- ff—�� --=---------- —_ --_ --------- — - -- ---- —10, --date— Permit No.-- —— . ---- Issued--- �- - - - - —— ---- - date r' !i!olGeb,lr♦iTIYTwQ,i?i!164�i!.i¢b?e4�46ltlblel�blif'i!i4gCiiTi464Gf64ili06TEAlef4litat6!(it8tA4i1i�!>!bi>felAe�orifw+lslObscrl.3Q$Wlr�✓�q!bISQ 9uri9&®e�a4�difja4aSdeila9il+4laTi�a?�9.51i9i BOARD OF HEALTH i TOWN OF. BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual del Constructed ( ) Altered ( ) or Repaired ( ) Installer at ------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health fPrrivate Well Protection Regulation as described in,the application for Well Construction Permit No,&__' -_I Dated � THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A.GUARANTEE THAT THE,WELL SYSTEM WILL FUNCTION SATISFACTQRY: DATE Inspector—--- --- ' — -- -----=--'.:------------- 'airli+'i!i4iY4�4a.W�4 ti1ti7�lifY9/.si'-'N!i►ia!iRFQY'�.M'EiibaRGli9.�!S�LaM,iTi=itr?idiQ34i'Bo4:H�t30aYt'm.'dm4LRiRVI'7liW befitl�78'��ilil.i4il4;f{lt1T,�!i!�'P1�4i4+�-i'!1�t?9!3 ?fy'Si!!iY^ytiM�i�.s BOARD OF HEALTH TOWN OF BARNSTA-BLE well.Con5truction3pertnit 000 q � i No. Fee— Permission is hereby granted to Construct ( ), Al er (. ), or.Repai ran Individu Well a street as shown on t e ap lication for Well Construction Permit : No.- ---- Dated . - -__— -- ---_-r ------ ------ If - =- 4 _ Board of Health DATE --