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0046 BURSLEY PATH - Health
�PUJXSLEY PATH,W.BARNSTABLE A=089-008 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r/ r� QJ 46 Bursley Path r a Property Address f* . Amber&Scott Gonsalves ' Owner Owner's Name information is required for every West Barnstable Ma 02668 1-15-2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 6/-*r ILI 3q,3 on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 n5 Company Address Sandwich Ma 02563 City/Town State Zip Code r�ur (508)477-0653 S113747 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 L 4. ❑ Fails -15-2020 Brett Hickey ""� °�a°a"" dz�oa,",s„o.�-0 �,.,a.�.�_«�s 1 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 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 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is west Barnstable Ma 02668 1-15-2020 required for every page. Cityrrown 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: The system was in working order at the time of inspection. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection C.Inspect ion 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 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every 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 El El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a 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 p Title 5 Official Inspection Form �ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 46 Bursley Path Li Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every St page. City/Town ate 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 ❑ Q Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El 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. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.) ❑ O The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails.) 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 t c Commonwealth of Massachusetts p Title 5 Official Inspection Form l^ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A 46 Bursley Path L Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every 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 Q ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? a ❑ 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? Q ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ a 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 Forin:Subsurface Sewage Disposal System•Page 6 of 18 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms (actual): 330/GPD DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes E] No Does residence have a water treatment unit? 0 Yes ❑ No If yes, discharges to: septic tank Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes El No Seasonaluse? ❑ Yes rol No See below Water meter readings, if available (last 2 years usage(gpd)): Detail: ***WELL WATER*** Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 18 - e c Commonwealth of Massachusetts p Title 5 Official Inspection Form m iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Bursley Path L Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: Owner- last pumped 2015 Source of information: Was system pumped as part of the inspection? ❑ Yes X 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 e lip Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2007 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 3 Depth below grade: feet Material of construction: ❑ cast iron ■❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: >100' from well to SASfeet Comments (on condition of joints, venting, evidence of leakage, etc.): 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 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town 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) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500gallons Dimensions: 6" Sludge depth: 30" Distance from top of sludge to bottom of outlet tee or baffle 2" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 15" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Bursley Path v Property Address Amber&Scott Gonsalves t. Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): , NA 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): NA -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 Title 5 Official Inspection Form I� I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is west Barnstable Ma 02668 1-15-2020 required for every 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 ❑ 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): 0" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. 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 �/� 46 Bursley Path Property Address Amber&Scott Gonsalves Owner. Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4 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.): NA * 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: (3)500 gallon chambers _❑ leaching chambers number: ❑ leaching galleries number: - El 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 - 4 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � � 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. 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.): The SAS was in working order at the time of inspection. Chambers had 1" of water when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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 ra Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA 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 LL , c Commonwealth of Massachusetts Title 5 Official Inspection Form ~ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every 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 •Well Driveway A Garage Rear Dwelling B 1 BI-49'5" A2-A260 B2.49'6" 46'9"A3.50'6" B3.54' ❑2 0 Q 0 l5insp.doc•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 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑� Surface water ❑■ Check cellar FOR Shallow wells Estimated depth to high ground water: No G W @ 144" feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record Oct-1-1997 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. 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 F cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Bursley Path Property Address Amber&Scott Gonsalves Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. Cityfrown 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 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 " .; i.1 . . .......I ,i .. : , . - . , .�,:..' :�il. - , . '..; -,..i., .. .. :T.:,,'; � .i--_1.- .-;; "I.-� - �----'!.�i,�1.�.__w �.::.- - , -1, ,;-...,,.1 i�.�i i- . , . .� � �!.1 7 . I _i \�5' li ,"'.,.;,.- . . ., �... - i ,� - .. 1 .. .,,. �..r,.,-�,�,:; -- '7,>.*:;:,��..:.�....I.. . ".i '.�;.;-' � � -i., , `v, - ..,�'., , ; , .,:it ,�'.;��;:;1�� - '. .��.� ,:��.� � . , .,.1. - r. . ;.'l I lu.r.11-_,.t'l .�."" i "'j. rW ;,� ._.,mw�� `�;-;-��*,':'l ,�.., I j I., �; .;... "�_ -�11 ( "1�'.."-..":;,i*,�--'. �. .� .�! � _ __ Town of Barnstable �gWE �+ Regulatory Services Thomas F. Geiler;Director • �nxtvsrnais. MAM Public Health Division Thomas NIcKean, Director 200 Main Street,Hyannis,NIA 02601 Office: 508,862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Q? o� n o1 - �g� a Date: 7 Sewage Permit# Assessor's Map\Parcel U Designer:�► �IJ ; �� 1 �, Installer: �4 a(7>l<S�` G4}'ls 4 Address: Pn Z3 b)(, �� Address: S-e4 F/i On . = �O �Ro%h!S Curr�� was issued a permit to install a (date) (installer) septic system at PATH-based on a design drawn by � 1� f (address) I .� p lJ 4'C r S s o dated 161, G designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. Greater than 10' lateral relocation of the SAS or anv vertical relocation of any component of the septic system) but in accordance with State & Local Regulations_. Plan revision or certified as-built by designer to follow. OF Mgss o DAR o -+ t er's ature o. 1 140 i IT to �(Designer's��n ature� (Affix Designer's Stamp Here) - - X's s(G. PLEASE RETURN TO BARNSTABL PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3_264doc TO N OF B STABLE ' LOCATION -SEWAGE#�i VILLAGE—( / ASSESSOR'S MAP&PARCEL C�C� INSTALLERS NAME&PHONE NO. � �r' F� Calf SEPTIC TANK CAPACITY ,/3270/ LEACHING FACILITY.(type) AL C�:� (size) /D /��d s NO.OF BEDROOMS OWNER PERMIT DATE: — Q COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ���� � inn R, �r � �, 1 e .3�;� -5 ���� .� No. �L� J Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Aptication for )Digagal *pztem Con0ruction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Apdress or Lot No. 'Vo/ l. ICJ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel rw Installer's Name,Address,and Tel.No. `�7 ��'t Designer's Name,Address and Tel.No. w 077d J. Type of Building: —�, Dwelling No.of Bedrooms Lot Size_ �S sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ® gpd Design flow provided Z�o gpd Plan Date OCI /997 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. t,e��. 64--, Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,/V e—g Le 4 f� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of e t Signed Date d o Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. a 0 O7— 2—9 a Date Issued 7 No. .. Fee / ? a" computer: ' THE COMMONWEALTH OF MASSACHUSETTS Entered in com p Yes i PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS r•j f t f.,i t. P Y cation' for�Miq;poml 6peum Cott.5truction Vermtt Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Iddress or Lot No., Owner's Name,Address;and Tel.No. J A rt a Assessor's Map/Parcel >® 04, A Installer's Name,Address,and Tel.No. �7/ Designer's Name,Address and Tel.No. , J Type of Building: Dwelling No.of Bedrooms •_. Lot Size f �- `S sq. ft. Garbage Grinder ( ) Other Type of Building /71v+-A_ ,rNo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design•Flow(min.required) gpd Design flow provided �s' gpd Plan Date OC/ 14'?7 Number of sheets � Revision Date Title Size of Septic Tank t ./,1 ) Type df S.A.S. Description of Soil w k Nature of Repairs or Alterations(Answer when applicable) _.. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate-of ` Compliance has been issued by this Board cf ie�alt Signed i Date a `d Application Approved by Date Application Disapproved by: Date for the following reasons " Permit No. 0 D U7- 2- 9 3 Date Issued - °2 ^a 7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIF That the On-site Sewage Disposal stem Constructed ( ) Repaired X Upgraded ( ) Abandoned )by at has been constructed in accordance r with the provisions of Title 5 an the for"Disposal ystem Construction Permit No. -�DO7 r 2'g3 dated 7 - 2-o7 . Installer Designer #bedrooms _� Approved design flow gpd The issuance of this pe •'t shal of be construed as a guarantee that the system w'Ififuhction as designed Date Inspector ———————— �———————————————————v-�- —————— No. y0-7_ 93 Fee (C10 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS =l5pagal 6ip5tem Con6truction J)erm t Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) > System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her.duty-'.'- to comply with Title S and the following local provisions or special conditions. S Provided: Construction must be completed within three years of the date of this permit. Date -7- 't O�7 Approved by lu wli of Barnstable # y 76 1 Department of Health,Safety,and Environinental Services Public Health Division Date 367 Main Street,Ilyannis MA 02601 BARMARLA f° Date Scheduled I # � — 7 - 9! 17 Time Fee Pd. 106> rED IA1N i Soil Suitability Assessment for Selvage Disposal Performed By: v ,gyp d J30Y -e Witnessed By: Nit, OWM� LOCATION & GENERAL INFORMAT.to. Location Address G� �s �� � Owner's Name Hg,& x�T2��'iAl CK L � Address a lri- M, ' 1�ay R5Xi� -s Engineer's Name Assessor's Map/Parcel: /�/� � � NEWCONSTRUCTION REPAIR 8 p� /� Telephone# �� 33 �—7�/>lAi7`�1 —" f���e Slopes(%) O1` �% 5`Y5Tre Surface Stones�7T & S6 Land Use V& � Distances from: Open Water Body n Possible Wet Area 266'f R Drinking Water Welln Drainage Way 240d ft Property Line ft Other R SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Lo-r 3s' i1F• _-- V Parent material(geologic)A/� S� Depth to Bedrock np � Depth to Groundwater. Standing Water in l tole: IVIf GEC (I ' t.Weeping from Pit Face / OAlt: Estimated Seasonal I ligh Groundwater DL`I'ERMtr A'I'ION FOIt SLASONAL Itq(dtll �'vE�.I<It�>it'xt, ,�A� - Method Used: in. Depth Observed standing in obs.(tole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment _n. Index Well N •Reading Date:, Index Well level Adj.factor Adj.Groundwater Level_ Pt,11COLATION TE 30 am Observation •- _ � / Z Time at 9" I tole# Depth of Perc �! Time at 6" m ort Pro-soak Time 0 I Z Z'0•U _-_ Time ff'-V) End Pre soak Rate Min./Inch < 2 MN 24-C� 71-14 gel /� 01W 3l 5-� . Site Suitability Assessment: Site Passcd_ � Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---� Copy: Applicant .;:.... llEEP:OBSERVATION l-tOL,E LOG.:- . . Depth from Soil horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. 0 2 Gravel) d- 8 fly 71Sye 3 k GOf m 16Y2 ? �f LOCI M 2,57 � / Ztt_ C FINE -9N.D 16A 8 / 5-, Ala ;DEEP:.OBSERVATION HOU LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % b1E>EY OBSI✓RVATION ROLE LOG.. Hole# Depth from Soil horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consiste cy.° Gravel) DEEP:OBSERVATION.HOLE LOG Hole# Depth from Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° Flood Insurance Rate Map: / Above 500 year flood boundary No_ Yes J Within 500 year boundary No— Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Y65 If not,what is the depth of naturally occurring pervious material? Certification � I certify that on � A - (date)I have passed the soil evaluator examination approved by the Department of Env ronmental Protection and that the above analysis was performed by me consistent with the required trai ' g,expertise and experience described in 310 CMR 15.017. A Signature � ^ ^9, Date�d � • / / • 77 • / I gill ® Complete items 1,2,and 3.Also complete A. Sign re item 4 if Restricted Delivery is desired. X O Agent ® Print your name and address on the reverser-,zAddressee so that we can return the card to you. B. Race by(Printed Named WDjatef D ivery © Attach this card to the back of the mailpiece,or on the front if space permits.1. Article Addressed to: D. Is delivery address different from item1? s If YES,enter delivery address below! lj�"o Ins 7o--x� Z-GCS 3. Service Type Certified Mali ❑Express Mail ❑Registered ❑Return Receipt for Merchandise Qo�/tp-/ ❑Insured Mail 13 C.O.D. 4. Restricted Delivery?(Extra Fee) 13 yes 2. Article Number (rransfer/tom service label 7 0 0 5 1160 00000191 3271 PS Form 3811,February 2004 Domestic Return Receipt 102595-024,1-1540 9 r9 Dryl/1fT1 m jam• I ' • ° Postage $ o _ certified Fee p r S 1 O Retum Receipt Fee �' Postmark b (Endorsement Required) Here 0 IAY 3 12007 [ 4 Restricted Delivery Fee )J A '(EndorsementRequired) 1 r9 r Total Postage&Fees LISPS O Sent o N - -------------------------- ----- et,Apt.No, or°PO Box No."/!9 l I C/ty._...-ZI ------------ - .; N Town of Barnstable CF tHE 1p� do Regulatory Services BARNSTABLE ; Thomas F. Geiler,Director 9� 63. ••� Public Health Division ArED MA'S A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 31, 2007 Ms Janet Bogle 46 Bursley Path West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5 The septic system located at 46 Bursley Path, West Barnstable,MA was last inspected on December 4`h, 2006,by Patrick M. O' Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: System is in hydraulic failure You have 60 days from the date of the system failure to bring the system into compliance. If there are any questions about this reminder, please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health e e COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION , � yaev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A _ p D CERTIFICATION Property Address: 46 Bursley Path West Barnstable MA 02668 r Owner's Name: Janet Bogle C Owner's Address: Same f a M. —wc Date of Inspection: December 4,2006 Job#07-104 Name of Inspector: PATRICK M.O'CONNELL , Company Name: SEPTIC INSPECTION SERVICES CO. = Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 c r~- Telephone Number: 508-428-1779 CYN � CERTIFICATION STATEMENT 1 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 Evaluatio the Local Ap oving Authority X Fa' s Inspector's Signature: Date: 12/4/06 The system inspector shall submit a copy of this inspection report t the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gPd or greate r,the inspector and the system owner shall submit the report to the appropriate re Tonal office f t o he g DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching chambers full to top. ****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. Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: ' One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 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 a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,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.] _Yes_(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 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ — Was the facility or dwelling inspected for signs of sewage back up? _X_ — Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X _ 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: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. _X_ _ 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)] Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):440 Number of current residents:3 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):No Water meter readings, if available(last 2 years usage(gpd)): N/A Well Water Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL 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: Tank pumped every three years. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system ` Single cesspool-. _Overflow cesspool _;Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) - 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 age of all components,date installed(if known)and source of information: 9 Years Were sewage odors detected when arriving at the site(yes or no): No i Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 BUILDING SEWER:XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_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: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete_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: 10.5'long x 5.8'wide—1500 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle:30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: STICK WITH HINGE FLAP. 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 is structurally sound,tees are intact and liquid level is at bottom of outlet invert GREASE TRAP: No (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.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 TIGHT or HOLDING TANK: No (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/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: XX (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.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): • Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number: Three 500 gal drywells. _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.): Observed liquid level at tov of structure,leachine system is in hydraulic failure. CESSPOOLS: No (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.): PRIVY: No (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.): { Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 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 100 feet. Locate where public water supply enters the building. i >> E.. $. • Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Bursley Path,West Barnstable Owner: Janet Bogle Date of Inspection: December 4,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water 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) Accessed USGS database-explain: You must describe how you established the high ground water elevation: A perc test will be performed prior to repair to determine groundwater elevation. CERTIFICATE OF ANALYSIS Page: 1 t '< ��" Barnstable County Health Laboratory Report Prepared For: Report Dated: 11/21/2007 Ralph Secino Willima Raveis Real Estate Order No.: G0744170 y 1284B Main Street Osterville, MA 02655 Laboratory ID#: 0744170-01 Description: Water-Drinking Water Sample#: Sampling Location: 46 Burs_Icy-I'_atli,_W,;Bai_nstablc,-MA Collected: 11/15/2007 Collected by: R.Secino Map 11486 Parcel 028 Received: 11/15/2007 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 0.35 mg/L 0.10 10 EPA 300.0 11/15/2007 Copper 0.14 mg/L 0.10 1.3 SM 31 11I3 11/15/2007 Iron ND mg/L 0.10 0.3 SM 3111 B 11/15/2007 i Sodit1117 13 mg/L 1.0 20 SM 311113 11/15/2007 Total Coliform Absent P/A 0 0 SM9223 11/15/2007 Conductance 130 umohs/cm 2.0 EPA 120.1 11/15/2007 pH 6.6 pH-units 0 SM 4500 H-13 11/15/2007 Water sample meets the recommended lintits.for thinking water of all the above tested parameters. Approved By- (La irector) F . \ ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 q1 19 v�-� 2 oVD P;TU ' coct k . � � 2ti ,�..® cr m �• -ice' I�� ' .�• o @ SEC Pa �,1� ofJOHN ;y �• 6'�1 ` �r4�®� ,�-�f' � qss P. H DOYLE,fit No.33589 v' �q�f�ISTfR���Q� • 7//4; J —A"1'� ON GOT �.•�- �': (_:'c7/Vf"�,rr'/V!S i if,��r. `��;J �si')C,.' /'ECJ/,!:'r';",•ol'�i�1�% EEO= �. �` Talv i , /' '.") r_:= A1V6 7f14r �T 1,5 IV4r �D�.4 i c: /N G'N T i E,l�ErC�L /i1/5�1 =%,tip A47 A141- i'-'c;•%� %�4 �;''�t/mil/�� /�/��✓e'%�i�BG�. ,`' 407" 1 TI' TOWN OF BARNST LE LOCATI ;N et r SEWAGE # �� VILLAGE S ASSESSOR'S MAP & LOT d - 6 b 9"' .INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Z;,,V ��` (size) NO.OF BEDROOMS BUILDER OR OWNER 'O _/—/,f 2 9 04"ZI PERMTTDATE: _l l- ��n COMPLIANCE DATE: - I 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 _ ��- nn �, �O 1 /� ! � � .. r, ,,. - No. FEE THE CO JMM NWEALTH OF MASSACHUSETTe P �� 9 //S G , MASSACHUSETTS W T 7 ,kyptiration for Visyveal **stem Tonstrurttuxt Ilerntit Application is hereby made for a Permit to Construct ( ) or Repair( ) an On-site Sewage Disposal System at: Location Address or Lot�/° ,/ // // / O is Napp�e,A7ddres a d Tel. o. /1 G Y �f Cfursy /V6 /�✓ �c:.tS �bf�4I /Crl ��jt7Q ��J� C �/1c. �6�.rf-J Installer's NW2e,Address,and Tel.No. Design ' Na ne,Address and Tel.No. AZ Type of Building: Dwelling No. of Bedrooms Garbage Grinder( ) Other Type of Building No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /d gallons per day. Calculated daily flow 270 gallons. Plan Date Number of she Revision Date Title Description of Soil �� � ./�1J yc✓►^ Nature of Repairs or Alterations(Answer when applicable) Date last inspected:. Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by>his Boar alth. Signed Date Application Approved by ' Date Application Disapproved for the following reasons Permit No. �� Date Issued -- S 1 1 -1 1 " < No. r,, w t{ FEE THE COMMONWEALTH OF MASSACHUSETTS_ /� MASSACHUSETTS '7- � 7 y,�kppliraxtion for Disposal Sgeit xn Construction ]Jerrait Application is hereby made for a Permit to Construct( ) or Repair( ) an On-site Sewage Disposal System at: Location Address or Lot No O ger's Name,Addres!a d Tel. o. ��li G✓ t�cr.,sd• �c l c f���aAe ���� Installer's Na nne,Address,and Tel.No. ys [r Design 's Name,Address and Tel.No. Ve 9 Type of Building: ' Dwelling No. of Bedrooms Garbage Grinder( ) Other Type of Building No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /t �/1��� gallons per day. Calculated daily flow 2 gallons. c , Plan Date Number of sheetsrr Revision Date � \ Title A/7�G h-i`I c�< Ale A, Description of Soil/ � "Loll Z",6;61 / Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar f 6alth. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 9 Date Issued THE COMMONWEALTH OF MASSACHUSETTS ,MASSACHUSETTS (germ£ irate of CfIImyliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed(Ny) or repaired/replaced( ) on by f r atrr { f k 1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires on p --� DATE ` / Inspector Gj-� p THE COMMONWEALTH OF MASSACHUSETTS No. L 3 rm" 6&0, �� —, MASSACHUSETTS FEE oo �is�IIBttl �gstPz�t C�onstr�tetton �Ermit Permission is hereby granted to / �°A`' %'� to construct(t�or repair( ).an On-site Sewage System located at t 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 completed within three years of the date below. DATE ../�" i''` Approved by ` -� r- n'FORM 1255 Rev.3/95 A.M.SULKIN CO.-BOSTON,MA , Bottie Number: 647b0i Date: 11%14/9*i O� BA BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT [-� SUPERIOR COURT HOUSE VBARNSTABLE,MASSACHUSETTS 02630 �lA 5 E' PHONE:362-2511 LAB 337 Ciient : ALL CAPE WELL Collector : S . F . H . maiiiiwi BOX L'tib Attili.ation : WELL DRILLER :�.dciress : BREWS'-TER MA 02631 Type of Supply_: W Telenhone.: 39b-8690 Well Depth: 92 FT Samole Location: BLARSLEY PATH Date of Collection: il/13%97 Tov.n: WEST BARNSTABLE Date of Analvsis : II 13/97 PAR.METLER SAMPLE RESULT RECOMMENDED LIMITS Total_'. Bactera/ 00 mL P 0 off _b . 2 im F crom4los/cm) 12l b00 I r oil: 4 ppxnr 0 . 6 0 . 3 (ppm) 0 . 4 li) . 0 aodzram 12 20 . 0 Copper er (p iio < 0 . 1 1 . 3 BASED, THE A,?iLYSES PERFORMED , THE FOLLOWING ADVISORIES ARE GIVEN : `Pt'i".s amaze-r sample exceeds the recommended maximum contamination. level t,;2-y• drinking water, due to the presence of Colitorm Bacteria . ' S-as,?d on t±ie results at the :)araineters tested ; the waYeL may present.. aesr_hetic problems (taste , odor , staining) due to iron. / I Lt� Thomas F. Bourne , Laboratory Director '.N { r x . BottleNumber: 650i0l Date;. 11/21/97 �� sa BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT O SUPERIOR COURT HOUSE 0 Aj BARNSTABLE,MASSACHUSETTS 02630 •. Y �j PHONE:362-2511 { LAB 337 CIiertz ANDERSON, BRAD Collector: BRAD ANDERSON Maili . ALL CAPE WELL Attiliation : Add1 BOX 126 BREWSTER MA 02631 Type of Suppiv: W Telepime: 896-8690 Well Depth: 92 FT Sample Location: BURSLEY RD Date of Collection: 11/17/97 Town: CST BARNSTABLE Date of Analvsis : 11/17/97 PAB: TER SAMPLE RESULT RECOMMENDED LIMITS a Total Ibliform Bay eria/100 mL 0 0 t pH ! Conc **.ivity (mi=omhos/cm) 500 Iron ( m) 0 . 3 �Vitr Nitrogen-�: �m) 10 .0 Sodilm (ppm) 20. 0 Cop» (ppm) 1 . 3 i BASF "' i THE ANAL'wKSES PERFORMED , THE FOLLOWING ADVISORIES ARE GIVEN: T} s is a Retesg i t. ner sample: ,.rieets the recommended limits for drinkinu water. s of all abrx,e tested parameters . // 7 Thomas .F. Bourne , Laboratory Director r i sY , F 1G , AA r _ No.--------- 7 y-Y1 Fee BOARDOF HEALTH TOWN OF BARNSTABLE Application-*rVell Con!5tructionpermit Application is hereby made fora permiLt to C nstruct (Alter ( ), or Repair (tan individual Well at: f _fin - ----- -- ----------- -------------- - - -- -------------- Location — Add Assesso s Map and Parcel -- - - -- -- - ---------------- - - x _ � -------- ----- ------ Owner Address GC t. --------------------------------- --------- --- ---- - - ----- Installer — Driller Address Type of Building Dwelling ------------------------------------------------- Other - Type of Building ------------------ No. of Persons--------------------------------------------------- Type of Well �f ---------------------------- Capacity-- - Purposeof Well------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed `3-- te Application Approved By+/ ----- --- -----N ---= ------ !�/� -l 7 -- ------- ate Application Disapproved for the following reasons:------------------------------------------------------------------------------------------------------- ------------ --- date _ q -1__ Permit No. -- -�- - --------------------------- Issued - ---�� ,?- 7---------------------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (f,ertifirate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed O, Altered ( ), or Repaired ( ) by------ �/-C � �'t�G ----------- --------------------------- ---------------------- ------------------------------------------------------------- Installer at P� �S Ups/ems1 ( ._ � / ---------------------------------------------------------------------- - - -- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection - <3_2_7__ Regulation as described in the application for Well Construction Permit No. ----------------97----c/7_Dated-/(--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- - ---_— -- - ---- -- Inspector------------------------------------------------ - ------------ •sh^"rr � ...�...�."' �:;"ifiMljFV....r� '_ t � el' ir Fee---- -- ------- - - BOARD OF HEALTH TOWN OF BARNSTABLE Application-*r Veil Con$truttionpermit Application,,is hereby made for ermit to C.nstruct (4, Alter ( ), or Repair V1 fan individual Well at: Location — Add Assessors Map and Parcel r l i J 0W1 � Owner Address Installer — Driller Address Type of Building Dwelling-- --- -?2-------------------------------------------------- Other - Type of Building------------------------------- No. of Persons-------------------------------`-- M------------- ` Typeof Well ---------- - - - Capacity--------------------------------------------------- - --- -Purpose of Well------------------------------------------------------------------ \Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of-Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. .1X �/� ,�� Signed ��---.------------------ - ------------------ -------I'-"/-/✓7 --�-- - ;� Application Approved By -- - - -1 -=--`-- -- -�/� - - flate Application Disapproved for the following reasons:-------------------------------------=------------------------------------------------ ---------------------------------------------------T---------------------------- q date Permit No. I-LIV -Y— - --------------- Issued-----. ------------------------------------ date sr�Gs:?�'��aa-zsrr�atas'aern�aq�s*aa'�ner���sc �s�amri:ee�se��. ae �ratstr BOARD OF HEALTH TOWN ,, OF BARNSTABLE �srtifiratrOf CompC cc ~ THIS IS TO CERTIFY, That the Individual Well Constructed X), Altered ( ),.or Repaired Installer at- o f 3 S `c, -------------------------- --- - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -�`' �=- ��-Dated--j�'- 3-' -�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED,AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------- —------------- - -- Inspector--------------------------------------------------------------------------- sC'°A--�•iy'-.s-"=r•�L�=�sr..w��s�icaz�a..s-....x xssasR�-�s-c�4�aeCsmye�s rar.r,��r:�si�.�.ae� �ce.+� _.. ?'-�ra��33-__ , BOARD OF HEALTH TOWN OF BARNSTABLE Melt Con$truct ion Permit y� No.W / 7_1-1-7 Fee- , Permission is hereby granted-'�4_--- �� �''� --r-�'e�/ to Construct Y", Alter ( ), or Repair ( ) an Individual Well at: 3 No. -��-® = 57 If t='Q-A ----L?a vh S `-' - ---------------------------------- ---------------------- Street as shown on the application for a Well Construction Permit 1 Dated--- - -1 �-7--------------------------No. DATE /3 Board of Health ------------------------/-----/------------------------------ TOWN OF BARNSTABLE LOCATION 76 �.LIAA�-e� /« SEWAGE # VILLAGE� �—� ASSESSOR'S MAP & LOTd�?— OoB' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �siize) NO. 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