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Home My WebLink About0080 HOLDER LANE - Health 80 HOLDER LANE MARSTONS MILLS A= 174 -001 -016 - Commonwealth of Massachusetts �-60/--01(o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 80 Holder Lane u- Property Address J Richard &Jan Wood Owner Owner's Name + information is required for every West Barnstable ✓MM Ma 02668 7/31/2020 page. Citylrown 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 fitting out forms A. Inspector Information 0017" on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane r� Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com 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 7/31/2020 Inspector's SignaturetizS7_ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. City/Town 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 80 Holder Llane West Barnstable is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 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. El Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 0118 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 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.7/2 612 0 1 8 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 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. City/Town 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® 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 +A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. City/Town 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 all inspections: Yes No ED ❑ 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) 0 ❑ 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? ED ❑ 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? ED ❑ 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 I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments aJ� 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 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 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ED No Does residence have a water treatment unit? ❑ Yes E] No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes E] No information in this report.) Laundry system inspected? ❑ Yes E] No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: ** property has irrigation system Sump pump? ❑ Yes El No Last date of occupancy: current Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 7 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. Cityfrown 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 I 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: 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 F� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 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 ❑ 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. El Other(describe): Approximate age of all components, date installed (if known) and source of information: original system installed 1996 Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: El cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form. f' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: 0 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 0! No Dimensions: 1000 gallons Sludge depth: 511 Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. 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 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Ls� Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. City/Town 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 ❑i 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 ❑i 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. City/Town 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: 1 El leaching chambers number: El 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 per_ City/Town 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.): leach pit was video inspected from d-box and was found with approx. 1' standing water and a stain line 3' higher. 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 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a! 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. City/Town 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 ,n Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 Pap. 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 4� vt 0 2 n �I 3 f3 131 37 (3 2 ''/n ,i3 y 3 131 `Y2 t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owners Name information is required for every West Barnstable Ma 02668 7/31/2020 page. City/Town 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: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: 11 Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 80 Holder Lane Property Address Richard &Jan Wood Owner Owner's Name information is required for every West Barnstable Ma 02668 7/31/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 0 A. Inspector Information: Complete all fields in this section. 0 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 I I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 - A Commonwealth of Massachusetts 1�'� ' �dl D((o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M re 80 Holder Ln. Property Address NJ Partridge i w Owner information Owner's Name is required for ere �GR JS Mil is MA 02668 9/21/17 every page. '� W Citylrown State Zip Code Date of Inspection NJ eMi t 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. General Information cS4 Idw Y 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/21/17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �'j qS- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M y` 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 3 bedroom septic per 1996 permit 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.doa•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The ❑ Y q P P 9 Y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6116 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 �< 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 City[Town state Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 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 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 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.doc•rev.6116 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 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 16.203 (for example: 110 gpd x#of bedrooms): n/a ; t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9121/17 Citylrown State Zip Code Date of Inspection D. System Information Description: 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 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 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 CityrTown 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: Pumped 8 yrs ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ . Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Holder Ln. Property Address Partridge Owner information Owners Name is required for every page. West Barnstable MA 02668 9/21/17 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1996 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑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.): Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 5 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 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 >12 Scum thickness 1/2 �2 Distance from top of scum to top of outlet tee or baffle 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 3 years to prolong the life of the system Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: • gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: • Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is 2'6"below grade and in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 Cityfrown 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.): Leach pit was video inspected, it is approximately 4' below grade, probing gives no indication of a raised cover, effluent level was approximately 18" below the invert, no indication of past fail conditions Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 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.): Soils are compact and dry 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.): i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. west Barnstable MA 02668 9/21/17 Citylrown 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 y^ 14 o �d t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >13' 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: 1995 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: TOPO mapping You must describe how you established the high ground water elevation: Plans on file show NGW at 13'. TOPO mapping puts the site approximately at 120' and nearest surface water is at 70' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Holder Ln. Property Address Partridge Owner information Owner's Name is required for every page. West Barnstable MA 02668 9/21/17 Cityrrown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 YtT 1 �-\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS c DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:50 Owner's Name* Owner's Address;` .0 .19(1 Date of Inspection' 3 ,Q (t ,cam o'ZS Name of Inspector please print)Ro -er4' n[Ablo: Company Name :fz. t .CLCt..LC.t�� Mailing Address:a ) -CERTIFICATION Number: , `' i"� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system.inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further'Evaluation by the Local Approving Authority F •ils / r Inspector's Signature: % Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health on DEP)within 30 days of completing this inspection. If the system is a shaPd system or has a desi n flow o 10 0TO., gpd or greater,the inspector and the system owner shall submit the report to the appropriate regidnal ofEiw,:of tha-r DEP.The original should be sent to the.system owner and copies sent to the buyer, if applicable,;and the provifie authority. r Notes and Comments r.) Tr ****This report only describes conditions at the time of inspection and under the conditions f 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. Title 5 Inspection Form 6/15/2000 page I '4 - • ji Page 2 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: wo-fie&, &L �A�, 7 � n Owere Date of Inspection 01J0013 Inspection Summary: Check A,B C;D or-E./ALWAYS complete all of Section D A. yytem.Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below.' Comments: B. System Conditionally Passes: One or more.system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair;as approved by the.Board of Health;will pass. Answer yes,no or not determined(Y,NND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally! unsound,exhibits substantial infiltration.or exfiltration or tank failure is 'imminent:System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass insp.ection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box.due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with . approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping.m-ore than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health); broken pipe(s)are replaced. obstruction is removed ND explain: 4 r?`i Page 3 of l 1 ;y OFFICIAL INSPECTION FORM;-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART(A CERTIFICATION(continued) Property Address: 1 Owner Date of Inspecfiok-_ ,I ! �'422= 4) Oo C. Further.Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board ofHealth in order to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any).determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 I 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 aseptic 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 DAP certifiied.Iaboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered:A copy of the analysis must be attached to this form. 3. Other: i t • k 3- ti r Page 4 of 1 I OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY`ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: (,� �e,G &AXe Owner(. -1 4& Date of Inspectio z D. System Failure Criteria applicable to all systems: You must indicate"yes or"no"to each of the following for all inspections: Yes N9 tf Backup of sewage into facility or system component due to overloaded.or clogged SAS or cesspool Discharge or ponding ofeftluent 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 Jcesspool _ Liquid depth in cesspool is less.than 6"below invert or available volume is less than '/2 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.well. Any portion of a cesspool er privy is within.50 feet of a.private water.supply well. aJ Any portion of.a cesspool ar 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 certdied laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presen.ce.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.] l +�O (Yes/No)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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems,in addition to the criteria above) 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 questibn 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. Page 5 of 11 ; ` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART B . CHECKLIST Property Address: ✓0' to Owne 'kT - Date of Inspection % .: ry �._ �� oo Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Ye�No Pumping.information was provided by the owner,occupant, or Board of Health iWere any of the system components pumped out in the previous two weeks ? 1Z as the system received normal flows in the previous two week period ? -Az-"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) LZ 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 V _ 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 owne-)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil.Absor.-ption System (SAS)on the site has been determined based on: Yet. no 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(3)(b)] 5 , 1 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM-;INFORIVMATION Property.Address: 5b l to ee. sL, _,, Owner Is Date of Inspection. %�L X0 FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design): . Number of bedrooms(actual): �f DESIGN flow based'on 310 CM 1.5.203 (for example: 11.0 gpd x#of bedrooms): / Number of current residents: .,�,G��.� / Does residence have.a garbage grinder(yes or no): Is laundry on a separate sewage system(yes'or ho):/l_If yes separate inspection required] Laundry system inspected(.yes or/ho): /V Seasonal use:(yes or no): %k/O _. Water meter readings, if avai-able(last 2 years usage(gp Sump pump(yes or no): Q 5 r Last.date of occupancy.. L COMMER.CIAL/INDUSTRIAL v Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date.of.occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records . Source of information: t Was system pumped as part of the ir. pVction(ye or no):_ g' If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM eptic tank,distribution box,soil absorption system �/SS ingle,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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate aye o all c ponents,.date installed(if known)and source-of linformation: =4y;a d a d A.& t/ Were.sewage odors:detected when arriving at the site(yes or no.):/VJ ,F , Page 7 of 1 1 Y OFFICIAL INSPECTION FORM-NOT FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM:INFORMATION(cor_tinued) Property Address: 9_ 0 / l Date of Inspection:: BUILDING SEWER(locate on site plan) � ) Depth below:grade: Materials of construction:_cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) ) Y Depth below grade: Material of construction: oncrete_metal_fiberglass.polyethylene _other(explain) If tank is.metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) . Dimensions: .�'j X (1 X 5 I Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: ✓L Scum thickness: rr Distance from top of scum to top of outlet tee or baffle: �r Distance from bottom of scum to b of.outlet tee or ba,fflf�:_ How were dimensions determined: ZC.A2, 1AJ Comments. on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels s belated to outlet invert, evidence of leakage, etc.): r .P VZZa a� GREASE TRAM ;(locate on site plan) Depth below grade:_ 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: 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 Page 8:of 11. OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: c -'t Owner. .. Date of Inspections >, a TIGHT or HOLDING TANK://stank 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/day Alarm present.(yes or no): Alarm level: Alarm in working order.(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: 11 present must be opened)(locate,on site plan)' Depth of liquid level above outlet inve-t: /�flJhout � Comments(note if box is level and.distriAon tetsjal,any evidence of solids carryover, any evidence of ,leakage into o. out f box,e PUMP CHAMBER:/��(locate on site plan). • ti Pumps in working order(yes or no)! Alarms in working order(yes of no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ; , / Owner. ' Date of Inspectioq- �� l)." 05 J SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: TYPe leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, `.fit'a )0V6-P A IPAeAA QJ Uh 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 or no): Comments(note condition-of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): I PRIVY:Z) (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.): 9 Page 10 of 1.1 OFFICIAL INSPECTION'FORM-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SE_WAGE=DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: V zlafe&f.., � Owner: Date of Inspections �G SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system.including ties to at least two-permanent reference landmarks or, benchmarks. Locate all wells within _00 feet.Locate where public water supply enters the building. 4ulnuk—, t 96 f INA 1 4�a t (;clo c a br) cp xcp Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ee SYSTEM INFORMATION(continued) Property Address:..,. Owne `., \ Date of Inspeetiol� �6. SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: . Obtained from system design plans on record-If checked,date of design plan reviewed: 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) VAccessed USGS database-explain: You must describe how you established the high ground water elevation: • F _ • 11 Permit Number: Date: Completed by: ,;-0 Y" - HIGH GROUND-WATER LEVEL COMPUTATION rM - Site Location: 0L ✓J,. r Lot No. ti> Owner: �Ql� crr% Address: Contractor: All�c�ll,S�` Address: IivaY? Notes: STEP 1 Measure depth to water table � to nearest 1/10 ft. .............................................. 1z /2fG�` :... ............................:... .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: P OAppropriate index well.....................................f:r� .. ZJJ OWater-level range zone ....................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... ��.�J / /z month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ................................. .............................................. 1 STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ............. s Figure 13.--Reproducible computation form. 15' qd TOWN OF B>>ARNSTABLE LOCATION ��d f O�1��G2 0�A-) SEWAGEZ VILLAGE. (f— °` �f1 ASSESSOR'S MAP & LO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /7— (size) 11000 NO.OF BEDROOMS BUILDER OR OWNER �S 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 �`� Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist XA within 300 feet of aching facility) Feet Furnished by 1— �L A.),Y,-1C 39137 3 �3 �z `� 2-9 �� No.-9' -=43L.rz FEB...... ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , ppliration for Di-nVntittl Work.6 Towitrnrtion Permit Application is hereby made for a Permit to Construct (V-�or Repair ( ) an Individual Sewage Disposal System ,o-r� lI3 . fro..... .. _._..... 1 ----------------------------------------------------------'--' n //Jress `��A�/a- /JJ/_ or Lot No: ..... .. ............ A dd 11 Owner 7" '"ln -------_Address W ��/� Installer Address d Type of Building Size Lot__��/_Q �� . Sq. feet Dwelling— No. of Bedroom�i. ----- Grinder_____ __. p ( ) ( ) a' Other fixtures ________________ ______________ __ --- ---- --------•---•- W Design Flow............................/CL?_______gallons per p .per day. Total daily flow_.______Z- Q_._____....._____.____gallons. WSeptic Tank—Liquid capacity-_/�UUgallons Length.-.------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet-------------------- Total leaching � area._...._...__...._.sq. ft. Other bution box ( " tl ) Dosing Date Results Performed by .Test 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........................ R+ 0 Description of Soil•-• 1frH------------------------------------------------------------------- x W ----- ------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------------------------------------•------'--'-•---•---''-••--•••----------•••----•-•--•-•-----------------...-•-----------------'--------------------------------------------•'--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersig ed further agrees not to place the system in operation until a Certificate of Complia bee Issued ky the bo -d of health. Signed ------------ -... .... .. . - --------------------- re ..... . h6 Application Approved By -- -------�^^...� ._...----------------------------------------------------------- ---------- ...... . Date Application Disapproved for the following reafonr: ----- ---------_--------------------------......... ..---------.-............................__..------------------------------- ----------------------------------------------------------__ ----------------------------------------------- ............ .. . ...._........._.............. ---------------------------------------- Date Permit No. g —--------------------- Issued --------------Z..-..14.....-f`�...................... Date 1 7 V. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE AVV iratiott for Di-1-ipw3al Works Towitrnrtion ramit Application is hereby made for a Permit to Construct (L, f or Repair ( ) an Individual Sewage Disposal System at: o ,!A10 ... r r, :�----------------------------------..-3--------- Loc tion or lot No. Owner / �� Address W 0 1 „ „.a r, ------===- --- _.I ------------------ - ---------- Installer Address d Type of Building Size Size Lot___17r..a.�_-�._.....Sq. feet Dwelling— No. of Bedroom� .__ _. .__. _-_�"__/�.�..�._..__Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building J7 i� 1 .-No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ------------------------------------------------------------- W Design Flow............................/�a,,....gallons per pelfon per day. Total daily flow......../ --------------_...........gallons. W Septic Tank—Liquid capacity__I��Ogallons Length________________ Width---------------- Diameter._._...._______ Depth................ x Disposal Trench—No. .....��. Width___ __.._.5 __ Ty ial Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.............._--._- Diameter.............----- De-p5, below inlet-------------------- Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by----------_ G<,t .._ ! .............................. Date.._.Z' �� ..�1............... a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water..................... r3;4 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................ a Descrl Description of Soil di. --1.�..'---- - ------------------=--------- ................................................................................................ P6 ------------------------------------------------•------------------•-------•-•----•-------•-------- V ............................................................. •------•----------••-----•--•--------•--•---••----------•--•••.........----•-•----•-----------------------............................... W ------------ -------------------------------------------------------------------------------------------------------- -------------•-----------•-----••-----------•-•-----------••......--•-•------••-- V Nature of Repairs or Alterations—Answer when applicable............................__-_.-..---_....................................................... -------••---•---------------•----------------------------------------...--------•--•-----•----••--••--••--•-----------------------------•--•--------•----...--------•-----------------•-----------.-•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compfa� bee sued by the bo rd of health. Signed ...... ... -............. _---------------....- ...... re Application,Approved By ----- - .. . . Dace K. Application Disapproved for the following rearon.r: -------------------__......--------------------------------------------------------------------------- ------------ _------------------ -- ------------ -- ----------------------------------------------------------------------------------------------------------------------................._......---------- ........................................ �y Dace Permit No. '---�-� ---� -------------- Issued ----------------------- ......... --------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE U-Ertifirate of GraptialarP THIS-IS TO CERTIFY, That the Indivi al Sewage Disposal System constructed or Repaired ( ) by ..1 - --r-' ------------------- �� ------------------------ ------------------------------------_- ._...-------------------._..--------- �s --��nf:iir'... at ....(/�''t...1..1. ...... .1Gf',Qr._� �<cn�--..... ----- "'�i! �-Jj....................................................................-------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ----- 5 -.U-- ------------ - dated .....: .. /. ..-..�/y j- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � --- - ------------------------------------....-- --- - Inspector .:. f -`'%' DATE----- - "' ..... - - `` '/' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �J IL TOWN OF BARNSTABLE No...l- Y ._.. FEE._.../. ........ �to�rnott�l—�. .ork� �u,,nf otr��rti.onrr�tit Permission is, hereby granted-...IV,.. •.----------/4f-:.._.-0-1--................................................ to Constr ct ( �) or Repair. ( ) am Individual_Sewage Disposal System f7�1�<��%X�r at No..-; -------`---./.ram+. ------------------------------------------------------------------------------------ Street 'J as shown on the application for Disposal Works Construction Permit No._ �_. _d- _. Dated--- ?. d._""/ '' Board of Health DATE �------... ------------L--/---------............................ FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS ' 0�C4IJ SI�1CaC� FAIIW 4 '5E-vFa,m4' c �o I,AZ5AGE 6RINVEZ. 1 DA I L-( FLOW 4x I to 4do epza SEFrl C TANV-- 4-4o x isp 4e o 4PD \0 I -PISFOSAL 'PIT Z-lovo,4A /I's row ff. 51DEW4LL APC-A = 50e7 sF � ,Da) > Sod 5F X z,c - '15v �PD �\ `#/ / \ BOTTOM Aa&& = I oo sF l Ire 47F I Ido�D, 114 TOTAL VA I L`r fir/ _ ZJD 44— T�E¢GaLAT1oN QATE �I 2.0 /L ays p� VeL UIS Pi TEER M� .e aAXT M, SULLIVAN NO.240e6 No. 29/33 �l \ OkA t Tesr a't�- TF IL 'Z `" viST �Nv 6AL �Nv iuv Boc L nr•� S�prIC �i�.� l000 T-ANL t Saun GAL �� (TQAC6i L P ik FeFD�.� WiS I G 1- 3/�Vz M� wasN� �: AL- Im cr uzes sicr Sam sToNE. ��-EE i MAP 1-14 Psi` l-1!, ` �yEloV� 'PQvFIc�-- ��l•Ff® PI.oT' �LAf�I I.GGATIDw :_ GE 4rL 1 I(o SGQ W Bi:zi.15. 5o DATE-J MAz I,Iq-7 5 1 C EYj-('F\ �-tom PLAN R-E�REIJC.E ( T� kr TILE awu ,AOVJW wlTµ Tt1S 5(DEUNE LOT 113 IZE4�' D� 'RIE- `fDWN O ?Ells FLAB: IS fJCT- Y3A� ok! AN t p �iSlvrJd�_ Aug Suev `/az5 l��T�vti4El1T' z��L E+JGt N EEz,.Svrz�c�f ArJ,U rN� �F-FSet-S �►�ou1� uu1- -�E uSC-1::> T ID GS,r/va % FW0 f 0 E2-T`/ N 5 STErzv i LLL MA'S4 oP�id SINGLE FAIRY 4 BE-vWa W • �o GA�3AGE Glzl►JpE7t � ' � � � � j .:.PAIL'-( FLOW 4x l lo-4-do GPza I . : SE•Pi'l C TANS.. duo x i� /�=GGo� �ti� /� � � � � � • 715Po5 ?IT 51DEWALL AREA = Soa 5F �4 I#/ / � BOTTOM At2zA = I no sF v,T'� ITorAL 'DA t LY rt.O / _ 4�o ,4� !,44— PE2CVC,A-MoN QATE :I" W 2AAIN /Lal-5 & ,1 1- I IZ •a� G2A�G. 5�orcr Pe � - � � a- �r v-OP06&C) _ veL o vi OF P TER SAXTEn p' SULL!YAN Maxaoco No. 29133 C �a 30 NAL 40L FG=i2/ 4 121 TF tL= i2-2 LorLtM ^ern_' � •._�•�� ---•-•�' � -•"7'77CT�'l77a'r� SvD 101 9 viST MIA/ GAL iav Bo�c i�� a�� SE.�rtc �•�� ! t Mom, 1ooC� w �i8.z SAyD TANL GAL �/Sr (Tq.A4,6 -SAGE} M� kz: ALL 5reucrvR0 s�T -TO gE ntv¢E 1ua�i 4' vr�� Cal . _.. ! 1. MAP 114 PAL I_I 1, r:erZrIF•I® PLdT' Locl�-TloN : Cet vi"G /w -- ' �i44.Lf=': DATA% yGdL ►,IR�tS N 0 W41BA, I FJzTi F� PLAN G RE�-E RQJC.E T44 AT T HS raw a"A v i� 5F1owfJ HEZEoN C.oM'Pr_ S WI-rµ 'TNS 5(pEUQS LoT 113 AitD IS I Dr L-o,,5AT*jE�D wiTgld THE vxoD M,&, ,l , 4 9 Nos INC. '79K l=Ldr !S NCT' r3A oN AN "1�vG4El1Tr P�F '7SIvrJdr_ Auk Su�V6 g- Sur?-VC-' ' AN,1D T'NC OFFSei"s 44vuLt) Q or USC-1� T�D EiTA LLIS E tz S[ rzv t1. MA CA W7 I