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HomeMy WebLinkAbout0127 POINT HILL ROAD - Health � 127 Point Hill Read �J-36--021 ..West_Barnstable 1 f f i No. 4210 1/3 BLU pendomff Hs)zp 10% o ® 0 900 z fV/ ---- (ENTRY 3 RV NOD. HALL I W.I.C. EX15T, �4 0 G L BEDROOM# LIVIN Big Ploom d Rl EXIST TTIU: T k �l­ NEW FLOOR PLANS New BATH- ------ EW OFFICE NE DINING- LAV. i! REVISIONS K IF New NEW MI, BAT KITCHEN NEW z ..7, �11 PANTRY 61 00 ---------- cq NEW DECK SECOND FLOOR PLAN 5CAUffl W-1'-0- 0 GENERAL NOTES: FLOOR TO CEILING 7'-S 1/2' �G CEILING TIES @ I W z 2, RAPTE @ I G' `5 2.B 8 RIDGE 1BOARD LEGEND O EXISTING WALL CONSTRUCTION TO REMAIN NeWWALI CONSTRUCTION EXISTING WALL CONSTRUCTION TO BE REMOVED 0 WINDOW SCHEDULE KEY OTY. MFG. STYLE MODEL# MUNT ROUGH OPENING REMARKS FIR5T FLOOR PLAN (A) I "-N DOUBLE HUNG !TDM040 AI SCALP:114--V.O' (d) 4 _H DOUBLE HUNG 11 GENERAL NOTE5: ID) 1 WWN DOUBLEHUW �1248 FHB No. sd3Avg FLOOR TO C.ZIUNG:7-8 1/2' (E) 2 MAWN — tAWN0527 DIIm 03/24/16 2,1 I 0 FIRST FLOOR J015TS @ I G'o- (1) 2 MARMN DOUBLE HUNG 2.0 SECOND FLOOR JOISTS®I G' —N IXIUGLEHUNG t­456 LEGEND OcLETING WALL CONSTRUCTION TOREMAIN 1MrLOW NOTES. NeWWAU.coI5TRucnoN ALLWIND-MBEANDERSEN-SMIES,ClADDGUBUEH­.­IITEIffi8­DHARG­IE ArA­­.,IA � ffl� �ETEMPE G�8$ N7OFWA� � � � �-18- MOR,� �MR& I:-3 EK15TING WALL CONSTRUCTION TO Be REMOVED H A 'PROGRESS PRINT NOT FOR CONSTRUCTION) Commonwealth of Massachusetts \v/ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTAB'LE MA 02668 10/10/12 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the I computer,use 1. Inspector: 1 only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 fedO1 City/Town State Zip Code 508-420-4534 S14297 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 10/10/12 InspectoPTSIgnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I t5ins•09/08 Title 5 T1sp.ction Form:Subsurface Sewage Disposal System•Page 1 of 17 r 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: OPENED TANK AND PIT BOTH WERE FUNCTIONING PROPERLY AT TIME OF INSPECTION. SYSTEM APPEARS TO BE ORIGINAL FROM 1978. CAN NOT PREDICT FUTURE PERFORMANCE UNDER THE SAME OR ESPICALLY WITH INCREASED USE. SYSTEM 1S OVER 30 YRS OLD B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09108 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 y 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of.a:.private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'.This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent.-and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Y rY ,M 5 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. Citylrown 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ` 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , ' 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A SEPTIC TANK AND 1000 GALLON LEACH PIT Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage WELL 9 ( Y 9 (gpd))� Detail: WELL Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every 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: 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): TANK AND PIT NO D-BOX t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: SYSTEM APPEARS TO BE ORIGINAL FROM 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 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: APPEARS TO BE 1000 GALLON Sludge depth: VARYING LIGHT t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cost.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness TRACE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,,evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of.17 l_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. Citylrown 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 NA 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): PIT HAS ABOUT 2 FT OF USABLE SPACE AT TIME , PIT APPEARS TO BE ORIGINAL FROM 1978 THERE WERE NO CLEAR SIGNS OF FAILURE AND CLEAN STONE COULD BE SEEN THROUGH THE HOLES IN THE LEACH PIT ABOVE THE LIQUID LEVEL. THE PIT IS QUITE OLD AND PAST THE NORMAL LIFE EXPECTANCY OF A LEACH PIT, FUTURE PERFORMANCE CAN NOT BE PREDICTED Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every 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 t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M ,•�''�< 127 POINT HILL RD Property Address GIBBONS Owner Owner's Name information is required for WEST BARNSTABLE MA 02668 10/10/12 every page. Cityfrown 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: greater than 4 ft feet Please indicate allimethods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date'of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: augered to 4 ft below bottom of pit no h2o encountered Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 127 POINT HILL RD Property Address GIBBONS Owner Owners Name information is required for WEST BARNSTABLE MA 02668 10/1.0/12 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file L,,5,n. /08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Assessing As-Built Cards Page 1 of 1 V?.-7,Fr - 307 CQT10N : SEW&C,E PERMIT WC VILLAGE -f GE Ns�a�le WSTQLLER'S U&ME ADDRESS BUILDERS Q &ME aDOREss I K�� ��'���•� /S' SC/41 �6u�er Pa tic( Dta"TE PERMIT ISSUED "��•6_'�S , OATE COMPLI &&ICE ISSUED : ,P l ♦V • o lid . rca n c�' 1 Div ' r ' Ck \f .. y Q ttp://www.town.bamstable.ma.us/Assessing4Mdisplay.asp?m4ppar--136021&seq=1 9/24/2012 I Certified Plot Plan wilcoi Location.• Ry 127 Point Hill Rd. SURVEYING • ENGINEERING X Bamstable, AA HOME PLANNING&DESIGN prepared for ffark Paci s GIDDIAH HILL ROAD PO BOX 4ss SOUTH ORLEANS,MA 02662 Scale: 1 u= 50' 508-255-8312 Date: April 1, 2016 www.ryder-wilcox.com j V PROPOSED a°'• DECK 16' X 30' 20 •8� " 0 60 � EXISTING Lot 6 6's, Area• DWELLING � yy 35,200 S.F.1- �6� (0.81 Ac."tJ EXISTING GARAGE •2,20 'o,.. �60 �,�' \6• 4 Refemnce.• Assr s map >36 Pcl. 21 I certify that the dwelling shown hereon is located as it exists on the ground and that as so located it complies with the minimum property line setback requirements of the Town of Barnstable. ILEP PH a DaM G . Professional Land Surveyor � SCri;fi_ I'-sITB # 67 glob No. 11666 ! O�Fss%O r Mlp I34 - Oil Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out ' Q forms on the (j onlycomp the tab key r,use 1. Inspector: to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name YQ P.O. BOX 145 Company Address CENTERVILLE MA 02632 feA0/ Citylrown State Zip Code 508-420-4534 S14297 Telephone Number License Number 8S—.3 I Md 1 a�7 A%jk 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 5-18-15 CK6pAWs Signa ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions;of use. h� t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pe of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: At time of inspection system just met the minimum passing requirements. The leach pit had 14 inches of usable space left. Future performance under the same or increased use can not be determined from this report B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*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 Y2 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 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 per town website DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form-Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: system consists of a 1000 gallon septic tank d-box and a 1000 gallon leach pit according to as-built Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: N.A Sump pump? ❑ Yes ❑ No Last date of occupancy: May 2015 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Debarros septic Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons gallons How was quantity pumped determined? tank size and pump truck Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r 91OZ311/9 1=bosWL£T8ZZ= dduui4dsr-XP1dsipy��uissassV/sn•ajguisuiugjoumol•mvnm//:dnq Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1978 per as built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: P feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Z3o Z 35td spiuD 11mg-sV�Iwssossd f 91OZ311/9 I=bosWL£I8ZZ= dduwZdsu-XuldsipWH/OuissassV/sn-olguisumgjoumol-AvAm//:dnq Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M °yt o 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top,of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relsted to outlet invert, evidence of leakage, etc.): Tank was pumped for maintenance at time of inspection. There was a small stedy stream of water entering tank at time of inspection indicating something was leaking or running in the house<the owner was notified of this and said he would determine the cause. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Z 3o Z 32m sp vD Ilmg-sV OuissossV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every 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.): i Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping:. Date Comments(condition of alarm and float switches, etc.): •Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i . Assessing As-Built Cards Page 2 of 2 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=025052&seq=2 5/14/2015 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 127 Point Hill Rd Property Address Gibbons Owner Owners Name information is required for West Barnstable Ma 5-18-15 every 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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Assessing As-Built Cards Page 2 of 2 t f . http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=025052&seq=2 5/14/2015 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): pit only met the minimum passing requirements at time of inspection with about 14 inches of usable space at time of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Q Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 L I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(not e e condition of soil, signs of hydraulic failure level of ondin condition of vegetation, 9 Y p g, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection pest n Form:Subsurface Sewage Disposal System Page 15 of 17 i Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M = ' 127 Point HIII Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property is located on a small hill well above the high water table 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 L � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Point Hill Rd Property Address Gibbons Owner Owner's Name information is required for West Barnstable Ma 5-18-15 every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 4 v9 7,F - 307 C&TIOP! ' 5EW&C4E PERMIT "0 VILLAGE 1NST1%LLER 5 llWE 6 h.DDRE5S BUILDER'S QLAME &.DDRESS / m I IC /� o V I j LO•V'? /.r SV��QWee DATE PERMIT ISSUED =6=�5 D NTE COMPLI&MCE ISSUED : Ilie "'r d U,3 4 0 a 0 • k °@ I PR`� . Q I http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=136021&seq=1 5/18/2015 � � �� C �� c,���` ��,il� �-. �- �,�r 3�U3°- S RCH1/___�_-, Fee----- = `-�- BOARD OF HEALTH TOWN OF BARNSTABLE JUN 0 2 2003 ritationore[[ �on�tructionermit TOWN OF BARNSTABLE HEALTH DEPT. - Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well 1 2 7Poi nth l_Bd�_---_—_ — ------ --�-- —_ D Q Location — Address Assessors Map and Parcel D Mike Gibbons — — 12.7___Point EjJ Rd_ --____ _ y oa ----- Owner Address 4 -M_eehan_ Well Drilling_—___—__________ Installer — Driller Address Type of Building Dwelling Dwelling---------_----_------------ Other - Type of Building------------- - No. of Persons---------------------- —__—__—________ Type of Well--Portable ---------------- --- 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 - ----------------------------- 5-30—03date ---- Application Approved By -—- --—-— --- D,,� date ` Application Disapproycd for the followin reasons:��` =— t/P.t+ri1s — ro,. Sci2 _ScSeu��_ n�t�J�/� %z "/L — —— 1 C.date Permit No.-------- - - -- Issued--- -- - - - - -- ---- ----- - date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of COMPhante THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by-__Meehan W-el1 -Drilling--- _ (Gibbons)------- -------- ----------------------- — --- Installer 127 Point Hill Rd. W. Barnstable, MA02668__ at- ----- - --- ------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection r Well Construction Permit No. ---------------Dated--- Regulation as described in the application for ------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. -- Inspector --------- ---- —__---- DATE----------- --- — Ins P BOARD OF HEALTH TOWN OF BARNSTABLE Veil Congtructionpermit 45.00 No. -----__�___� Fee--_-_�____ Permission is hereby granted Meehan Well Drilling .(Gibbons) ___ _ to Construct ( ), Alter ( ), or Repair ( ) an Individual Well at: --------------------- ----------------------------- _Street as shown on the application for a Well Construction Permit No.-- -- Dated-- ------------------------------------ Board of Health DATE— -- __ 45.00 -- No.---------------=----� Fee------------ ' BOARD OF HEALTH a ' TOWN OF BARNSTABLE Applicat ion-*rVell ton!5tructionPermit Application is hereby made for a'permit to Construct.( . ); Alter (. ), or Repair ( )an individual Well at: y 'H i I I R d ` Location — Address Assessors Map and Parcel -Mike Gibbons _ -- -- i 7 Point-_ jL;-1 1_Rd_ - —/� ' U r ` l --— Owner Address Meehan Well Drill-in Installer — Driller / Address Type of Building Dwelling- D we l 11 ncq------------------------------ Other - Type of Building- ---- --- - No. O ersons-= - — ----- ------ �_:.-.eF-'—�".+.7s-.a...:_•-�a,--^�••-e.:-.� f -....Y-rya,-; _...v r' .}�. .'_.a"�;".:�i�3ta..-•.—_::3+� .a. ._�..... _.. Type of Well—Portable ---_ Capacity----------- acit ----- ------------- R P 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 P --=- ----- 5-3.0_0 3----- date Application Approved By - gate ' Application Disavoroved for the following reasons �'r� �u'� —�' s/ ---="�~-> c/a�treu se�LAc = t-m;t�t.__OAc__suSeEr _ xss�,_ _ll �' - S Permit No. — -- ---- Issued---— ---- --__-- -- ---- - Ij date _ BOARD OF HEALTH -TOWN OF - BAR NSTAB.LE C ertif irate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) t Re.eh a n u� _n�; i "; �_ ------- -- --- -- -(Gibbons)------- - —- - _Installer �. R 1.21 ` Point' Hill Rd. _W. Barnstable, MA '02668, . has been installed in-accordance with the provisions of the Town of Barnstable Board of Health Private Well`Protection I ' T Regulation as described in the application foi 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—__---------___-_-- ---_—__--- BOARD OF HEALTH TOWN Of BARNS1TABLE Ivell construct ion Permit � No. , 45.00----- I Fee- Permission is hereby granted Meehan Well Drilling (Gibbons) --_—_--_— to,Construct ( );.Alter ( ), or Repair ( ),,an Individual Well at: ( No:— -- — — - -- - - Street ..as shown on?the application for a:Well,Construction Permit - ' No:- _ •Dated-- -_ ----- - - Board of Health DATE r I y1�~ V9 7,F 307 CATION ' 5EW&GE PERMIT QO.o _West 13gi-as44L/e S4: ,cVy &C'k_ — - - —� 1 IWSTQLLER'5 U&NIE 6 ADDRESS BUILDER 5 Q &V AE ADDRESS / � K". �,� �.� �g �s Su4`6cuec, - - — — — — — — — //v/I�roa /f &995s- — — — DINE PERKA T 15SUED 79' — - — — D ATE COMPLI &KlCE ISSUED : . i .v - j o lid � a� PAC A% V97,F _ -307 CATION 5EW&C;E PERMIT UO. L po ltdl _LVO /-716 VILLAGE (oC5 — CVe I3gl`N,3447L e SWcl, /Vcc/C_ — — INSTQLLER 5 U&ME--�� ADDRESS OA OC Y Mq�44 51. BUILDER 5 1. &V AE ADDRESS eke (3.4Loov� rs sv /6cue� DNTE PERMIT D D.TE COMPLI W-ACE ISSUED : — — — e+ ` y� ' a7tn� No.............1A.7 Fps.....24................ F THE COMMONWEALTH OF MASSACHUSETTS �a BOAR® OF HEALTH due ................. ... . ....oF........... ..._...-_.._.-...--------_-----.__.-.--------- II y ja Vp ira#ion for Dhiputia1 .larks Tow3trurtiun grub Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage al J System at: 1.3(p __ ..�.. �G L Pf ----..... 6 �.� .......�................ -------------------------_... ---••-••••-_....- .......... ........ 42 krcat SAddress f or Lot . ..... . ....-•(--..1._.....•�----•-----------------/-----,-/------- ......... ,C..�._.. nA.._.i^..((J.f.Of,�---•----------•---....................•-•-...-- Wslim% (NG��� �'�� GU t Cd ers a ! -- ---....---•-------••---------•--•••••....._. Installer Address Type of Building Size Lot. Zz7V____..Sq. feet Dwelling—No. of Bedrooms............�_�.............................Expansion Attic ( ) Garbage Grinder WO) 04'4 Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures --------------- --------------- - WDesign 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....1A......... Depth below inlet....... .... Total leaching rea..................sq. ft. Z Other Distribution box (�f Dosing tank ( ) O/- /9G - b`"17- -7i-. Percolation Test Results Performed by.......................................................................... Date........................................ aTest 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........................ x .........................k�--- -- .. ¢Description of Soil----------jO---... _"............. ------ --------------- ------------------------------------------------------------------ Y _.... 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 iITA TLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ...... _..-- - .. Datg Application Approved By. � � a Y .�.. Date Application Disapproved for the following reasons:------•----------------•-•-•-•---------•--•-----.._..------•-----------...------•---••......--------•-------_... --•-----------•-----------------•------------•--------------------------------------......-•-------------I---••-•-----------••---•-•--•--•-••-------------------••-•-----•-----..__------•-••----•••-•--- Date PermitNo......................................................... Issued................ / k Date No.. ........1A.7 r F�s..... : t .........._ THE COMMONWEALTH OF MASSACHUSETTS,10* ,r' `z BOARD OF HEALTH OF.......... �..... � " ............................................ Appliratiou for UhnVaii al Yorks Towitrurtion Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a> t l 1 -- ..... ...... ................. ......... ................................. ....... .......... ... ....... . ....... ..... ......... -• ocation Address �* or Lot No 'JOEc.3 / Glr 'c. ' a --•................. ........... ..^---•• al-•---...---- Address ... wo Type of Buiill�ding��� Size Lot- Z.�C .----.Sq. feet U Dwelling—No. of Bedrooms............44 ..:.............................Expansion Attic ( ) Garbage Grinder Other—T e of Building No. of persons............................ Showers ( ) — Cafeteria ) 04 Other fixtures W Design Flow__.. •-gallons per person per day. Total daily flow '�' gallons. W Septic Tank/—Liquid capacity/ ......_gallons Length___... Width................ Diameter................ Depth................ W _ -• ---_•- Total leaching area.... ...........s ft. xDisposal --, t_ _. -------- Total Length--------- g q• Seepage Pit Trench No.-�o Diameter Width ®__._...... Depth below inlet...... ...... Total leaching area.. .............sq. ft. � - Z Other Distribution box (j##` Dosing ,(..; ) a � �A Percolation Test Results Performed by............ •---------------- Date - aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth.to ground water........................ ........ ----- w. . O Description of Soil L'!~..! .... t:.. f". `....... tt x z. #......... •^mot r, ` 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 LITL P 5 of the State,.Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed --- ............................................................. D at Application Approved By---- al� � ..... Date Application Disapproved for the following reasons:................................................................................................................ ..........................--•------------------••-•-------------•---•-••--------------•----..............--------------•---------•---------------------------------------------------------------------- Date PermitNo......................................................... Issued............................. ........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 0& HEALTH ` ............. .............� 'Py" ..OF........... G"'9 .4`�"`1. All rdifiratr of Timptlaurr .......................... T. IS TIFY t tr! ividual Sewage Disposal System constructed ( ,0r Repaired ( ) b _ __ ............................ `_...... 1.. ................aller U _...._. .. .............4` ".... .Instal._ - -•- -- -4 `-- - ._- L has been installed in accordance with the provisions of T 5 of The State Sanifary Code as escribed in the /� application for Disposal Works Construction Permit No +�S.+�. ............ da.ted___4 '" ¢--.' .. .------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. l�..�..[- �� ... ... ... Inspector--�.. --.• -- ............ l THE COMMONWEALTK OF MASSACHUSETTS BOARD OF' HEALTH `�� - ...2..........OF............ ... Qrl -� No...... �d .7._ FEE too o � rruti Permissio�i ereby granted /� .... to Construct l ) r air ( ) an Individual ,4a e D• y em at ....43_L V !�.... ....r1�......' ----- --•---..... Street- as shown on the application for Disposal Works Construction Pe No.:___ ated._., ._,'. ". .. -........ ?' � '. BoO. iRl, lt ah x DATE............................................................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ..:.�.-:: r s 3110�r-�®s.,I1 �•� Jl y�'� 't�Al�a�,, RX� ems:-_- �. . I law. JD NW 00=20A . r l�llbir'4 OV44CAr MAX - IT AA*V f � ice PI p �-�• �4,x � � r11�G FBI�'� �„a►'� a � �` I I o ` ��`•P v• i + OI^ * "r- �`. ,l;+: 1 \ ,(vim=`11 VI5 9bi�Ti� ' 6-7? 10 A'M 2.j50 3� ``�r:Y;,����»►/..r ��o / '�►/���..._. o� ALA J� �+ pip- cot f� 'ft+ '� GoNs-(�cti�'7F'� 5'TWC7L •, ��t.� �o / INN% . w� '1�•Oc Ivr����`'-� Tip 4 Ih{.f �L• ONAIEVk . Avl � "f" ...�..�..--- Q c^� INV• INS• � 41 may. SA"TorPl? Y � , all 7717 for. No 1104010(c. E ,aWOW }AIL• � ` I� � o ;�'� Yt 7• 4 N01P • . Wit,.ep. rt'ato f�i #,•�;