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HomeMy WebLinkAbout0029 TILLAGE LANE - Health 29 Tillage Lane W. Barnstable y Commonwealth of Massachusetts / 3�r 003 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner information is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. Cityrrown 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. A. Inspector Information 5190 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1/12/21 InspectorVoignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �n (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Tillage Lane Property Address Owner Phipps information is Owners Name information required for every West Barnstable MA 02668 1/12/21 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: i 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts ,io Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner Owner's Name information is required for every West Barnstable MA 02668 1/12/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner information is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t; 29 Tillage Lane Property Address Phipps Owner information is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts � (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner information is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for aH inspections: 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner Owner's Name information is required for every West Barnstable MA 02668 1/12/21 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom permit on file at BOH Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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: Well Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �a 29 Tillage Lane Property Address Phipps Owner information is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped October 2020 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps inform owneration is Owners Name required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy EJ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1995 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 6 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments 29 Tillage Lane Property Address Phipps inforrn Owneration is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, covers raised to 6" of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: trace Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness trace Distance from top of scum to top of outlet tee or baffle y2" Distance from bottom of scum to bottom of outlet tee or baffle >2" 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 29 Tillage Lane Property Address Phipps Owner Owner's Name information is required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner Owners Name information is required for every West Barnstable MA 02668 1/12/21 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 D-box is 4' below grade, cover raised to 6"of grade, no adverse conditions observed t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner information is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 9 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner Owner's Name information is required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrators were video inspected and are dry at this time, no indication of past hydraulic failure, bottom of chambers is approximately 5' below grade 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner information is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner Owner's Name information is required for every West Barnstable MA 02668 1/12/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 �1u Pr r' `6- A\3® a ,r' �1 I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 CommofiW01th of Massachusetts Title 6 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner information is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >10 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: n/a Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4'seperation per 1995 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 42'msl and nearby surface water at 32'msl You must describe how you established the high ground water elevation: In addition to the above per the 1995 permit obs. gw is 14'or greater Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Tillage Lane Property Address Phipps Owner information is Owner's Name required for every West Barnstable MA 02668 1/12/21 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/62018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION ko7— �� -77 LL /9G-E SEWAGE# VILLAbE L✓ —���'� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEFRe CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER �/IAOas PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 9" l b l ad f?r o �'/ �� /=�o.vr- r TOWN OF BARNSTABLE LOCATION Q �� �'�� !� SEWAGE# � VILLAGE Affl/ mow! a ASSESSOR'S MAP&LOT/S —®03 INSTALLER'S NAME&PHONE NO. �O✓�'O�C//T� CO/P�Sr 7�� '`13py SEPTIC TANK CAPACITY /Sa d LEACHING FACILrrY: (type) NO.OF BEDROOMS BUILDER OR OWNER &P, PERMTTDATE: �l� `"` S COMPLIANCE DATE: �..� � Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of.Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by E , r a �, �-� a9 , � � � � /�s � r _ 30, ���- /o� a No. Fee 30 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Otgpogar *pgtem Congtructton Permit Application is hereby made for a Permit to Construct( )or Repair V,)an On-site Sewage Disposal System at: Location A dregs or-Lot N 4 *5 C_ Owne �o dress6,d Te ANo GJ , 6A1Lnrs�c� , �/►� Gd-o I e"r'Name,Address,and Tel.No. Designer's Name,Address and Tel.No. G�pUJ'37�N Cfli..lSi7L �( LdvJCl�li'Z'i�.e'T/ a�}J - '7(es` L-J WtFR`/ 44 Type of Building: Dwelling No.of Bedrooms _3 Garbage Grinder("-j AU Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow -7 gallons per day. Calculated daily flow AW® s�-V gallons. Plan Date P z Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) Th+JjZ- <s=- 60 JL 9 zlrEl V fig! � ^ crlU2.ocJ h1 Date last inspected: Agreement: The undersigned agrees to ensure the constructio 'of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by th oardkf Health. Signed Date l 9� Application Approved by Application Disapproved for the foll g reasons Permit No. �� 1 7dW Date Issued / / _ � '-,fe.�',...1•.—f%�O 1 7, A ;ae r •� 5r1 13V P�C/�' 30 ---- Nq. Fee THE COMMONWEALTH OF MASSACHUSETTS PUYBLICdHEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for -Migpozal 6potem Construction Perm-it / Application is hereby made for a Permit to Construct( )or Repair�,/,)an On-site Sewage Disposal System at: Location Address or Lot No. Owner LName ddressd,Tel:g�.S — o S"a- I er _Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 0 C t v►J .tS /t 1 +/►�L 1115, vVtLb G \. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( U Other Type of Building No. of Persons Showers( ) Cafeteria( ) rt Other Fixtures �1%' t. t 1 Design Flow gallons per day. Calculated daily flow Me —sr t— gallons. Plan Date cl y 4'6� Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) /n1.S�`��tA. L Tih-ts) Yd{ DsST 60 i.,J1�_-j t_%2a,UVf W .3�% ._S--rTJ u/ZA-VLJ►..,�INS - Date last inspected: 1 Agreement: - G The undersigned agrees to ensure the constructi ce of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 o the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thisI oard4bf Health. Signed / Date Application Approved by ,. Application Disapproved for the foil 'ng reasons � p C� �/ w. Permit No. ^/ 74� Date Issued ! / t =_=__=_____-___=__-- THE COMMONWEALTH OF MASSACHUSETTS 1 j De 3 .; PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS .. Certificate of (Compliance - THIS IS TO C RUFY,that the On-site Sewage Disposal System installed( )or repaired/replaced b4e)on G t,u„ z'11r��c-tv�t for by ' 1 as ��� � �;�7 .�. � �- 1J11. ) - has been constructed ija accorAance with the provisions f Title 5 and the for Disposal System Construction Permit No. 17-kV dated . Use`of thi .' stenids con doe n.compliance with°tlie provisio et forth below: v f t`t �No. / ( 3� 03 Fee 3� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS wigoar *p!5tem (Construction Permit Permission is hereby granted to - O"-W GU AJS j—�L.,Vc::77 P'N to construct( )repair( t>4n On-site Sewage System located at T/UL !�t; t5�l�. �.41C,.►�.a�'L�,. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be comple d within two years of the date below. Date: / cmrs' Approved by r - ------------ � loz --------r--- k6 1 4 3 1 ' C, l(u � f�� v *' 'S } ia1`a �. .* 2�f 2 i5 2 �' i. P e.F •s� 2s zat Y +,•.a %S k € � !' "+per,• ! g� �P �� 4't.'z� '} ww NNE MEN e +v xz'frfxasl - - .. r' Ps - F-SKETCH AND APPLICATION FOR A DISPOSAL <>? � �b Mx TWO PERMIT D J�N (WrMOUT ESIGNED P S) r � IN 19 a constru ion permit s g ie by me dated concerinng the VI 1-1 VP Pot a�ed at ^7 meets all of the - fopowin' g cntena: f • there are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leachingfacility - / t3' - There is no increase in flow and/or change in use proposed There are no variances requested or needed SIGNED: DATE: /� r9C LICENSED SEPTIC SYS M INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Mich-a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. t - mix y •; y..r r �,..x-� �'„� r"y�, v;Jr ?i" -'�z ��5. ,may-.--t. a " FY-/7�oP Town of Barnstable Department of Health, Safety, and Environmental Services r ' UMSTAHM Public Health Division FD a 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health October 25, 1995 Brad Phillips 66 Fuller Brook Road Wellesley, MA 02181 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at Lot A & B Tillage Lane, W. Barnstable was inspected on May 20, 1995 by James Sears a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Less than 100 feet, but greater than 50 feet from private well with no water quality analysis. • Also, evidence of the cesspool full to the cover. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health r � qY TOWN OF BARNSTABLE LOCATION 2 Q r'i e 1N. SEWAGE VII,I,AGF; W .�jA/I'l3 t�le ASSESSOR'S MAP&WT 1 INSTALLER'S NAME&PHONE NO. SEPTIC.TANK CAPACTI'Y L:EACHIING..:FACILITY: (type) L t t�r12 s (size) liX� L 9 NO.OF"BEDROOMS BUILDER OR OWNER ��� �� PERMITDATE: y !s COMPLIANCE DATE: iHd Separatio'Distance Between the: MaximumAdjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site:.or within 200 feet of leaching facility) FCe.. Edge of Wetland and Leaching Facility(If any wetlands exist i within 300 feet of leaching facility) Furnishedaiy a • •... • ��-� /off No. 9.J—/7aQ Fee 3o—o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppfication for wgpogaf opgtem congtruction Permit Application is hereby made for a Permit to Construct( )or Repair W,)an On-site Sewage Disposal System at: Location Ad1rej ,�ot No. Own e�' yam�e,Address d el. .�� / / �E C./+�1 E ��D�• t FPS I r' Name.Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms c.3 Garbage Grinder(---r^ju Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ?� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) i4- —sw PnL 77clije— 11 Date last inspected: Agreement: The undersigned agrees to ensure the construction of the afore described do-site sewage disposal system in accordance with the provisions of Title 5#the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by th' oar f Health. i Signed Date Application Approved by Application Disapproved for the foll g reasons Permit No. /� 74:pv Date Issued -------------—_-------- _---.-------------- /--- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO C ,that the On-site Sewage Disposal System installed( )or repaired/replaced on by '0/t�e,t..0 1, 1.1 CMt J for Pam. .--.. ..4 /l ANI/RAJ 1 as �7, ) - has ben constructed ' acco d nce with the provisions of`title 5 and the for Disposal System Construction Permit No. 7� dated . Use of thi system is con 'tio n compltante with theprovisio et forth below: No. Fee �U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Wgpogaf Opgtem Congtruction Permit Permission is hereby granted to 11�_ ?0►2_T_G 'G4&J S i/LVc.;7 rN to construct( )repair( s4n On-site Sewage System located at ,�i4/G,.1 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be omple!within two years of the date below: Date: /�j !S Approved by Z 3148 6S1 018, ` Receipt for Certified Mail 0 No Insurance Covers_ge Provided �0sr.M5 Do not use for International Mail POSil sEpvlCE (See Reverse) rn rn L Stree 2% � tea Z ode O � ostage $ CO) c Certified Fee � r , Special Delivery Fee CO) a f4`'slerri`n,bwll 'r`ry tf'e Wt[Srn^AL*6-d"jilt li?�aw t6 Whom&Date Delivered Return Receipt Showing to Whom, (,N G0 s Date,and Addressee's Address TOTAL Postage or &Fees 9 Postmark or Date A. I -Y �J 1 STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). m 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address In leaving the receipt attached and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return � address of the article,date,detach and retain the receipt, and mail the article. rn L 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article.by means of the gummed ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. G CD 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, co endorse RESTRICTED DELIVERY on the front of the article. 0 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If U- return receipt is requested,check the applicable blocks in item 1 of Form 3811. a 6. Save this receipt and present it if you make inquiry. 105603-93-B-0218 Town of Barnstable • �• Department of Health, Safety, and Environmental Services MAM Public Health Division �D 367 Main Street, Hyannis MA 02601 office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health October 25, 1995 Brad Phillips 66 Fuller Brook Road Wellesley, MA 02181 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at Lot A & B Tillage Lane, W. Barnstable was inspected on May 20, 1995 by James Sears a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Less than 100 feet, but greater than 50 feet from private well with no water quality analysis. • Also, evidence of the cesspool full to the cover. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health k� [Installer letter] TO: A � ` �1: (Date) - ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. a��� � The septic system owned by you located at was inspected on X—o? 0 9A- Y OW A4 01- "-� a Massachusetts icensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable N's SENDER: "t V ■Complete items 1 and/or 2 for additional services. I aISOCWISh-to EeceIVQ the i rn ■Complete items 3,4a,and 4b. follouSing sbrviceS(fclryan H ■Print your name and address on the reverse of this form so that we can return this extra fee):, ♦ r card to you. , U` ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address permit. 1 dam-■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N ■The Return Receipt will show to whom the article was delivered and the date a delivered. Consult postmaster for fee. 0 : 0 '3.Article Addressed to: 4a.Article Number d z 3 E 4b.Service Type-0t ` ❑ Registe d 10 Certified W rn W 3�0 ❑ Expressil ❑ Insured c w ¢ ❑ Return Receipt for Merchandise ❑ COD C 0 a , J .Datg rDery Z `/ D $ .f 5.Rec ivedy: rint ame) 8.Addres ee's dd ess(Only if requested and fee is paid) t T6. X ture:(Addressee or Agent) M t PS Form 3811, December 1994 Domestic Return Receipt I 'a UNITED STATES POSTAL SERVICE'' �- -- Postage&Fees Paid usps� ® Print your name, address, and ZIP Code in this box G f . r Health Do MUM Town of BaMSW " P O.Box 534 Hyannis,Massachuso 02601 8 4 r Z -348 .650 995 Receip* for Cer++tied Mail - NdAnsurarrce Coverage. Provided �� Do not use for International Mail _ I (See Reverse) ec�s Sen't o� rn et a d No. r L 2 P ,Stat and ZIJPCode C ✓ ..y 0 Postage M E Certified Fee / 8 Ll LL Special Delivery Fee V) 4 Best?icted''de9iWN ee etuYn^ eE§i�S'$S�o`tiSiK'� to Whom&Date Delivered Return Receipt Showing to Whom, Date,and Addressee's Addresser tl-. TOTAL Postage &Fees a Postmark or Date �g�, STWK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, 1:ERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not-want this receipt postmarked,stick the gummed stub to the right of the return address of the article,date,detach and retain the receipt,and mail the article. rn t 3. If you want a return receipt,write the certified mail number and your name and address on return receipt card,Form 3811,and attach it to the front of the article by means of the gummrd ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECF10T- REQUESTED adjacent to the number. C 4. If you want delivery restricted to the addressee,or to an authorized agent of the addessee, rj endorse RESTRICTED DELIVERY on the front of the article. E o 5. Enter fees for the services requested in the appropriate spaces on the front of this r return receipt is requested,check the applicable blocks in item 1 of Form 3811. ' ti z 8. Sa.e this receipt and posgm it-if you make inquiry. 105603-£ i rn -f Town of Barnstable BARMAeM = Department of Health, Safety, and Environmental Services MAN Public Health Division 6s9• 367 Main Street, Hyannis MA 02601 i Office: 508-790-6263 Thomas A McKean FAX: 308-775-3344 Director of Public Health September 27, 1995 James Sears AB CANCO CO. 350 Main Street W. Yarmouth, MA ORDER TO COMPLY WITH 310 CMR 15.009 THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system inspection conducted by you at Lot A& B Tillage Lane, W. Barnstable was incomplete. Your inspection report indicated the system failed to protect the environment. However, the report was missing the following information: • No water quality analysis submitted (leaching facility is less than 100 feet but greater than fifty feet from private well. You are directed to submit a complete inspection report to the Town of Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis). Also, please clarify your handwritten notes on the bottom of"part C". Sincerely yours, Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health I Coda [RECEN �D SEPTIC PUMPING AND INSTALLATION 350 Main St. W. Yarr iouINEMA OkA95 775-2800. K ' Heating 8 Plumbing,Fire Sprinklers TOWN OF BARNSTABLE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP ORM Address of property lbw a�.�RTi��Ls9�£ �N MAP# Owner's name aRA� ���PPs Date of Inspection PAR# ©� 3 PART A CHECKLIST Check if the following have been done: Pumping information was requested of he owner, occupant, and Board of Health. pl ovsi CLosr,o �P . 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. IV14 As built plans have been obtained and examined. Note if they are not available with N/A y/ The facility or dwelling was inspected for signs of sewage back-up. ` I The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. Alh The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. RECEDED AUG 3 1 1995 i�+tntu� c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms O number of current residents garbage grinder , yes or laundry connected to s stem, yes or no seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available: ���y��✓ Last date of occupancy GENERAL INFORMATION Pumping records and source of information: AIR C r 3�IrPA, 5 F,;1-1- 10U,0�4-7)-- System pumped as part of inspection, yes or o if yes , volume pumped 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) Other (explain) Approximate age of all components .'mponents . Date installed, if known. Source of information: Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B �� SYSTEM INFORMATION continued SEPTIC TANK: ( locate on site plan) depth below grade: material of construction: concrete metal FRP other (explain) dimensions : sludge depth 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 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, recommendations for repairs , etc. ) DISTRIBUTION BOX: A1 O ( locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal , evidence of solids carryover , evidence of leakage into or out of box, recommendation for repairs , etc. ) PUMP CHAMBER: �V o (locate on site plan) pumps in working order , yes or no Comments : (note condition of pump chamber , of pumps and appurtenances , recommendations for maintenance or repairs , etc . ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : A1 O ( 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 leaching pits and number leaching chambers and number leaching galleries and 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 , recommendations for maintenance or repairs, etc. ) � S I CESSPOOLS ( locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer dimensions of cesspool SXS 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, recommendations for maintenance or repairs , etc. ) PRIVY: N OAI"c ( 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, recommendations for maintenance or repairs , etc. ) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH 'OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' wt� rxa v7 lo DEPTH rO GROUNDWATER depth to groundwater method of determination of approximation: I f i . SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes , no , or not determined (Y, N, or ND) . Describe basis of determination in all instances . If "not determined" , explain why not 01/ Backup of sewage into facility? Al Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 da . / flow? N Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial enfiltration? tank failure imminent? Is any portion of the SAS , cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 .feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? N/ within 50 feet of a private water supply well? I less than 100 feet but greater the 50 feet from a private water suppl. 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. V 0 C Fs"s,�06oL L A/G o V fR /�La c✓ P S 8 GRS£ v .S&.4 �do77-4n 9doL �VL Cav£� oat_ v.v�CA. 5-1 z c �dc vn% � Nam vP f , SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name A & B Canco Company Address 350 Main Street , West Yarmouth MA 02673 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate and complete as of the time of inspection . The inspection was performed and E. y `recommendations regarding upgrade , maintenance and repair are c ; sistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems . Check one: I have not found any information which indicates that the system fail to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated J n . /the FAILURE CRITERIA section of this form. v I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. NOTE: A & B Canco has had no control over the use and/or routine maintenance of the septic system. Circumstances such as a recent pumping will significantly alter evaluation results . No guarantee or warranty is herraby given , express or implied , as to the evaluation. THE ISSUANCE OF THIS INSPECTION FORM SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY if you have any questions , please call me at 508-775-2800 between 8 : 30 am and 4 : 30 pm, Monday through Friday . Inspector ' s Signature Date Original to system owner Copies to: Buyer ( if applicable ) Approving authority PA F-k' R E t c-"I•t.rEN E-3- G c--_S ri r zx e 1- y r-I cl ut r,y Fl el y L F-'arc e 1 d 1:36.. Accourrt No' '7"':'.,:!.-9 F,ia r p r,t ' b )o l 7 B 13 � 9 Gkt. ori TTL.LAGE 1. ,AB Ei clevel, L":3 t L e 7j. Ar.-.res, CUrrent 0 w n F'HIF'F't::). WILL. All L State,.) EGAN, GAF,,Y F i?.! JE"A1"41 F No. 'Bldfl2s 1 Al,ea. 6,6 FLJ L.L E-IrR, BRC),01.,'. RD IWIELLESL y Deed 147 PH I P!'S WILLAAM L & 1.1eed MIIIUEI' IC'- I. Eeerll rr"e"' 77-20 "O'­A Dl-::,rriirlents:� e Va 1 UEDS 1-Zan LJ D U i I d J. g Road Syt-Aert." I F'l d e,.:.- I "r L L.AC3 E'-' LANE.. F*,,,-1 n t g Con-trol Info," 1 Asit At..dto Ur)d: S-Lactus., C Last Land F;'.F..)vj.e.wed B­ Bldop,--..i By, A., 'T,.-;.;: T i t 1 e,' A(---c c)u n.1- "I""a r:C._5 n C:C t 't -S 1.d �3 t 61 C)LA!1 9 e,,t U 1 MIT for, rriore -dat'..a screc.?n iF,A F -t­t J.on 0 w rl e r,S N a 1TI(,.:� Roaci Narrie Paj.rcel Nurriber 1 C.C.it pnver �� SEPTIC PUMPING AND INSTALLATION 350 Main St. • W. Yarmouth, MA 0'A • 775-2800 Heating&Plumbing,Fire Sprinklers October 19, 1995 RECEIVIO Town of Barnstable all) OCT 2 4 199 - Public Health Division VM ffm OR 367 Main Street Hyannis, MA 02601 49 S Re: Lot A & B Tillage Lane, West Barnstable Dear Tom McKean, On October 1, 1995, I received your letter regarding an evaluation on the above property stating that we should do a test on the well water because leaching facility is less than 100 feet but greater than 50 feet from a private well. On October 18, 1995, I spoke with Brad Phipps (508-359-4692) the owner of the property. He informed me that I was not to go to the property or to do a test on the well and that he would contcat the health department himself. Sincerely, PP�� d� i James Sears Septic Inspector Town of Barnstable Department of Health, Safety, and Environmental Services 9 MASS°"�'; `� � Public Health Division 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health September 27, 1995 _ . James Sears AB CANCO CO. �s 350 Main Street W. Yarmouth, MA ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,TITLE 5. Tillage Lane W. Barnstable BT ae you at Lot A& , `The septic system inspection conducted by y g , was incomplete. Your inspection report indicated the system failed to protect the environment. However, the report was missing the following information: • No water quality analysis submitted (leaching facility is less than 100 feet but greater than fifty feet from private well. You are directed to submit a complete inspection report to the Town of Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis). Also, please clarify your handwritten notes on the bottom of"part C". 3, Sincerely yours, Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health r s