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0093 CAPES TRAIL - Health
93 Capes..Trail West Barnstable A.= 088 -014 / TOWN OF BARNSTABLE LOCATION 9 3 apes ���(� SEWAGE#. �®a� --' ib-) VILLAGE_�1-, ��r s to�,� ASSESSOR'S MAP&PARCEL i INSTALLER'S NAME&PHONE NO. JCfS �c-G�/•�L(. SEPTIC TANK CAPACITY j LEACHING FACILITY:(type) u\ C ,S(size) I NO.OF BEDROOMS 4 a ci OWNER PERMIT DATE: 7) 12 OO COMPLIA CE 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) •I U feet. Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BYCC ��G� � �� = �� t� � � �® A► � � �� � \ ^ � y ,� 1 0,��� � 3 � ;� � _ ® �--� � � � � ' + f No. .�°C.�J�� �O� Fee l�� .�--- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Mi!6pogal *pgtem Con.5truction 'Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. co, Owner's Name,Address,and Tel.No. �,1•QGSe�s1���. �1 L�Gv{-�.►. tMUf'�� 7 Assessor's Map/.Parcel ` Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. scv E# F" , L4- 'So V2&-a 1 a t d 2 j Type of Building: Dwelling No. of Bedrooms Lot Size 14Q -)QL`_ sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) U gpd Design flow provided z?y gpd Plan Date ft(, (O 5l Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. U L) 5 Description of Soil _ ��..� A e J Z V tJ - S jr" Gr'�_��LZ�?w�./Q`tJ 1. 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 of Health. Signed Date f 10 Application Approved by ,. S , Date '? Q 1 Application Disapproved by: Date for the following reasons Permit No. 2 009^ 3 0 - Date Issued /� B ./fA + No. .goo el �0� •y�:� r � .�° _ �� �� � t ` Fee THE COMMONWEALTH,,OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS a Applitation4or Mi5p0a i§p5tem Cougtructiou Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. q 3 CCU L Owner's Name,Address,and Tel.No.' MU<1,4Vy Assessor's Map/Parcel d 3 Ca ,2:c L 6 I. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 5Cv Et G 0 cz- �4 1 C S � �d -y 2 J v��v� cS 5 1�ti Type of Building: Jar Dwelling No.of Bedrooms Lot Size k�ej sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 gpd Design flow provided gpd Plan Date t(a O�j Number of sheets Revision Date Title Size of Septic Tank (y C> Type of S.A.S. Description of Soil Fs r. C J Cnn I C �ti!`Q b�nc�` -/ (�+ L.) �( �k� -! C0$. ps 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 of Health. Signed Date 9 6-7 10 Application Approved by �• S Date �J�i ? 09 , Application Disapproved by: Date for the following reasons Permit No. 2 UGC(^ G �7 Date Issued ° THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( I/� Upgraded ( ) Abandoned( )by sCo \� at Cl3 Ce. S V• has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Zak- 2-,o dated 0� Installer sC O�\ I�ca�-•V Designer le CL S #bedrooms Approved design ow 3 v A gpd The issuance of this permi shall not be construed as a guarantee that the system will function as designed. Date e1 ��J Cl Inspector No. Zav� ^ �� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS 1=i5po5al J§p5tem Construction Permit Permission is hereby granted to Construct ( ) Repair (V15 Upgrade ( ) Abandon ( ) System located at (� 3 C G" rC—,k L L--> (`V. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and'fhe following local provisions or special conditions. Provided: Construction must be completed within three y ears of the date of this ermlt. Date % /` p U p Approved by • o88-alb . Commonwealth of Massachusetts I? Title 5 official Inspection Form ' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �� 93 Capes Trail p p,•a Property Address r. Dan and Phyllis Mooers : Owner Owner's Name r information is W. Barnstable MA 02668 11-13-2019 required for every page. City/Town State Zip Code Date of Inspection , 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. Important:WhenWhen filling out f A. Inspector Information �j. 1ya�, on the computer, use only the tab Darrell Stone key to move your Name of Inspector cursor-do not Cape Cod Septic Inspection use the return Company Name key. P.O. Box 1466 ree Company Address Harwich Ma 02645 City/Town State Zip Code � (508) 240-2500 S14995 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 Y 3. ❑ Needs Further Evaluation he Local Appro on y 4. ❑ Fails r 11-19-2019 Inspect 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts _ Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 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: ® 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: 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): - f5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts n ,ip Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments u= 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name informationis required uired for every W. Barnstable MA 02668 11-13-2019 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.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) j ❑ 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 >.5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � % 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is W. Barnstable MA 02668 11-13-2019 required for every ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS'or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® - Any portion of a cesspool or privy is within 50 feet of a'private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ The system fails. I have determined that one or more of the above failure® criteria exist as described in 310 CM 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 Title 5 official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 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 ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ Were an of the s stem components pumped out in the previous two weeks? ® Y Y p P P ® ❑ 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)] f ,6inso.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �s 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name required for is every W. Barnstable required for eve MA 02668 11-13-2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom residential dwelling Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): a Detail: x s / Sump pump? ❑ Yes No Last date of occupancy: Current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq'ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 'Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5inso.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts im Title 5 Official Inspection Form � Subsurface Sewage Voluntary Disposal System Form - Not for Y Assessments `C 93 Capes Trail v Property Address Dan and Phyllis Mooers Owner Owner's Name information is W. Barnstable required for every MA 02668 11-13-2019 page. City/Town 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. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2009 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"+/- - feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Apparent good condition t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 4 Commonwealth of Massachusetts Title 5 Official inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 page. City/Town State Zip Code Date of Inspection Da System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 26"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 101, Distance from top of sludge to bottom of outlet tee or baffle 22 411 Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural.integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grade to inlet and outlet covers 12" Normal liquid level No sign of leakage SCH 40 outlet tee Recommended next maintenance pumping within 1 year Recommended maintenance pumping every 2-3 years =.5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �b Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 93 Capes Trail L Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 page. Cityfrown 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: s ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): . r Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts IR Title 5 official Inspection Form '= I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 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): 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.): Grade to box 41" Cover 25" 2 outlets with speed levelers No scum Normal liquid level No sign of leakage OK condition No sign of failure ,Sinso.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 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 page. City/Town I State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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 Forth:Subsurface Sewage Disposal System•Page 13 of 18 C Commonwealth of Massachusetts �m Title 5 official inspection Form . _ .�/ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 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.): 4 infiltrators with 3.5' stone Grade to SAS 45" No sign of hydraulic failure 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.): ;5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts �R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for .� Y Voluntary Assessments 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is W. Barnstable required for every MA 02668 11-13-2019 page. Cttyrrown 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 �x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 93 Capes Trail �J Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 page. CityFrown 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 p l;�_&to I I A � 3 I i i t5insp.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 Fora I� Subsurface Sewage Disposal System Form -Not for Voluntary oluntary Assessments � 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is W. Barnstable required for every MA 02668 11-13-2019 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: >5 feet Please indicate all methods used to determine the high ground water elevation.- Obtained from system design plans on record If checked, date of design plan reviewed: 2009 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Elevations from the design plan Bottom of SAS ELV. 95.9 ' Bottom of Test hole ELV. 90.9 NWE Separation >5' 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 Commonwealth of Massachusetts .13 Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Capes Trail Property Address Dan and Phyllis Mooers Owner Owner's Name information is required for every W. Barnstable MA 02668 11-13-2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Ti ht/Holdin Tank— Pumping contract attached 9 9 P 9 For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Capes Trail Property Address Teresa-Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 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. General Information on the computer, use only the tab 1. Inspector: �I key to move your cursor-do not Trevor Kellett use the return Name of Inspector key. TK Septic Inspections Company Name 38 Vacation Lane Company Address West Yarmouth MA 02673 Citynown State Zip Code 508-579-5502 S113744 Telephone Number License Number B. Certification .. . I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/22/2014 r Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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•3l13 Title 5 0lfidal Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 r 47 4'tv \. lid " 1 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in'310 CMR `!5.304 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Capes Trail Property Address II Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or_break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): L C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. 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 El ® clogged SAS S or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than%day flow t5ins•3/13 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is West Barnstable MA 02668 8/21/2014 required for every page_ Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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- 10,000g pd. ❑ ® 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 A ❑ ❑ 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 corisidered 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 I� regional office of the Department. t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "w 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1+ Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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? ElYes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No ' Water meter readings, if available: t5ins-X13 Title 5 Official Inspection Forth: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 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ . Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records,if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 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 93 Capes Trail Property Address Teresa Murray Owner Owner's Name required fo is West Barnstable MA 02668 8/21/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 9/17/2009 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.8 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.).- Septic Tank(locate on site plan): Depth below grade: 2.2 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: T. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is West Barnstable MA 02668 8/21/2014 required for every page. City/Town 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 27 2" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1 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 ofleakage, etc.): Septic Tank is water tight and structurally sound with both tees intact,there is also a sealed off, abandoned pipe in the outlet end Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments 93 Capes Trail Property Address Teresa Murray Owner owner's Name information is required for every West Barnstable MA 02668 8121/2014 page. 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 worldng 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•W3 - - Title 5 Official Inspection Forth: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 93 Capes Trail IP'l Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable + MA 02668 8/21/2014 4. page, 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 even 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 level and watertight Pump Chamber(locate on site plan): Pumps in working order: ❑, Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): .System is equipped with 4 infiltrators in a 10'x38'x10°field of stone dug down to the stones and found no high staining or ponding 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 75ins'3113 - Title 5 Official Inspection Forth: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 u 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is West Barnstable MA 02668 8/21/2014 required for every - page. City/Town State Zip Code Date of Inspection ` D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,*condition of vegetation, etc.): t5ins•3/13 - Title 5 Otfidal Inspection Fonn,.Subsurface Sewage Disposal System-Page 14 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Capes Trail _ Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below. ® hand-sketch in the area below ❑ drawing attached separately r Al) 14' A B A2)39' A3)48' 131) 14' P'. B2)50' 133)61' O • it O 3 �2 • r. r,, �..,.. Pt.. •. wro_ i Y t5ins•W13 ° Title 6 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official- Inspection f6rm Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (coot.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 170 Estimated depth to high ground water: 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: As built show gw at 150+ft ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS Maps show ground water between 170 and 180 feet Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Forth: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 93 Capes Trail Property Address Teresa Murray Owner Owner's Name information is required for every West Barnstable MA 02668 8/21/2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Olfidal Inspection Form:Subsurface Sewage Disposal System•Page 17 of V Town of Barnstable �FTHE l Regulatory Services Thomas F. Geiler, Director BARNSTABLE, 1639, Public Health Division A�fD MAC A Thomas McKean, Director 200.Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: pq Sewage Permit# a� �3�7Assessor's Map\Parcel Designer: !S�,l�p �{C� /,. VAAA� PE Installer: 5C'0T1 _ ►A. � �►— E ACd L_C S is tW f a=G 11.4t. Address: 9 Z3 p,&v;Z e,A Address: YA9j-c&u-nt On. k k'-1 pcl :SCO-17— w.(, / was issued a permit to install a (date) (installer) i septic system at 9 3 �S �Gcwv based on a design drawn by (address) S 1,P 5 A. 14AA5zt:., Pam_ dated (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 any 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. MPHEN A. BAAS' (Installers Signature) CIVIL ®.354BAL (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE 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:\Septic\Designer Certification Forni.Revised.doc Town of Barnstable P#_ ) � 6 �- � oF� . Department of Re gulatory Services / > L, 2 Public Health Division Date ( 039. ,b� 200 Main� Street,Hyannis MA 02601 y Date Scheduled Time L __ l -�L�L__117 Fee Pd. l UU Soil Suitability Assessment for Sewage isposal Performed By: e �h-� A (-hrgAS PE Witnessed By: Location Address LOCATION& GENERAL,INFORMATION 3 C GC-2-e e t� C� � S -+CZ�� Owner's Name. G, � fv*\vr Address t n"e Assessor's Map/Parcel: 6 .- O f C( `r t� Engineer's Name NEW CONSTRUCTION REPAIR V Telephone# Land Use Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) �9 3 Parent material(geologic) Aoz beo--Z's 5 Depth to Bedrock R Depth to Groundwater: Standing Water in Hole: N1 Weeping from Pit Face �e+ Estimated Seasonal High Groundwater _ 0/, DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: /-10 Depth Observed standing in obs.hole: in. Depth to sail mottles: Depth to weeping from side of obs.hole: in. In, gr,Index Well# Reading Date: Index Well level in, factor, J,�� - Ad Adj.droun1lwaterLevel,,,,�, PERCOLATION TEST bate oS Time i I;�, Observation Hole# Time at 9" 1ru Depth of Pere - � Time at 6" 64 7 Start Pre-soak Time @ O:"� :47 l Time(9"-6") End Pre-soak . - �,•'VC, Rate.Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) - Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\S EPTIC\PERCFORM.DOC DEEP-OBSERVATION HOLE LOG &HoleDepth from Soil Horizon Soil Texture Surface(in.) Sdil Color(USDA) (Munsell) oulders.avelLS . Depth from DEEP OBSERVATION HOLE LOG Hole# _ Soil Horizon Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Munsell) Mottling (Structure,Stones,Boulderrs. EEry Consiste %GtLS F, _ — av l) 2v " DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. UFove, DEEP OBSERVATION HOLE LOG Hole# [Depth from Soil Horizon Soil Texture Soil Color Soil Other rface in. USDA (Munsell) Mottling (Structure,Stones,Boulders. onsi ten I w { Flood Insurance Rate Mao• Above 500 year flood boundary No Yes 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 occurrirg parvicus material exist in all areas observed throughout the area proposed for the soil absorption system? ,Z If not,what is the depth of naturally occurring pervious material? Certification I certify that on 1 44114 (date)I have passed the soil evaluator examination approved by the ' Department of Environmental Protection and that the above analysis was performed by me consistent with . the required traini a pertise and experience described in 310 CMR 15.017. Signature Date QASBPTIC\PERCFORM.DOC b f Ott ENVIRONMENTAL E O "'i'"E C H , 0�< 8 199, FA���FPTIgBC 4 THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE CHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 93 Capes Trail,West Barnstable Address of Owner Date of Inspection: April 22, 1997 (If different) Name of Inspector:David D.Coughanowr,R.S. Company Name,Address,and Telephone Number: Eco-Tech Environmental 43 Triangle Circle Sandwich,MA 02563 (508) 888-0185 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 functio and maintenance of on-site sewage disposal systems.The system: X Passe PN,SF1 OF,y�q Condi asses rSp Ne f er CAtq§tio Local Approving Authority � G Fai COUG D'N WRm+ ` Inspector's Signature ~ �j Date: 4P t r %q NOTE==> A septic system' Sew/STS al Estate Transfer Inspection if it does not trigger any of the failure criteria listed below.The septic sys d according to the conditions observed on the day it was inspected. No estimate or guarantee of system Ion i ade or implied by a passing determination. The System Inspector shall submit a copy of this report to the local Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. ; INSPECTION SUMMARY: ' N Check A,B,C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired.The system,on completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances. If"not determined", explain why not The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltradon, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the BOARD OF HEALTH. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 93 Capes Trail,West Barnstable Owner: Donald and Velia McCortison Date of Inspection: April 22, 1997 B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken orobstructed pipe(s)or due to a broken,settled,or uneven distribution box.The system will pass inspection if(with approval of the Board of Health): broken pipe(s)is/are replaced _obstruction is removed distribution box is leveled or replaced. The System required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s) is/are replaced obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety,and environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _CESSPOOL or privy is within 50 feet of a surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 foot to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and that the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: _ I have determined that the system violates on or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should contact me to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 93 Capes Trail,West Barnstable Owner: Donald and Velia McCorrison Date of Inspection: April 22, 1997 D) SYSTEM FAILS (continued): Static liquid level in distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SOIL ABSORPTION SYSTEM,cesspool,or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 foot 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of systems is 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 within a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA) or a mapped Zone I I of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.Please consult with the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 93 Capes Trail,West Barnstable Owner: Donald and Velia McCorrison Date of Inspection: April 22, 1997 ' Check if the following have been done: X Pumping information was requested of the owner,occupant and Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. X As-Built plans have been obtained and examined. (Note if they are not available with N/A) X The facility or dwelling has been inspected for signs of sewage backup. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the soil absorption system.have been located on the site. the septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,depth of liquid,depth of sludge,depth of scum. X The size and location of the soil absorption system on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of a Subsurface SEWAGE DISPOSAL SYSTEM. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 93 Capes Trail,West Barnstable Owner: Donald and Velia McCorrison Date of Inspection: April 22, 1997 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 2 Number of current residents: 2 garbage grinder(yes or no): no Laundry connected to system (yes or no):yes Seasonal use(yes or no): no Water meter readings,if available: Private well Last date of occupancy: current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow gallons/day Grease trap present: (yes or no): Industrial Waste Holding Tank present: (yes or no): Non-sanitary waste discharged into the Title 5 system: (yes or no): Water meter readings,if available: OTHER: (describe): Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS(and source of information): System has not been pumped is recent past System pumped as part of this inspection (yes or no) If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic tank,distribution box,soil absorption system single cesspool overflow cesspool privy shared system (yes or no) (if yes,attach previous inspection records if any) Other(explain) APPROXIMATE AGE of all components,date installed (if known)and source of information. Age:6 years.System installed in 1991-permit#91-420(BOH files) Sewage odors detected when arriving at site: (yes or no) no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 93 Capes Trail,West Barnstable Owner: Donald and Velia McCorrison Date of Inspection: April 22, 1997 SEPTIC TANK:—X (locate on site plan) Depth below grade: 18 " Material of construction:X concrete metal FRP Other(explain) Dimensions: 8'x S'x 4' Sludge depth: 10„ Distance from top of sludge to bottom of outlet tee or baffle: 24" 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:fir" Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) Maintainance pumping of the tank recommended,Liquid level at outlet Invert.Tees and tank appear in sound structural and operating condition No evidence of leakage in or out of tank GREASE TRAP: none (locate on site plan) Depth below grade:_ Material of construction: concrete metal FRP Other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 93 Capes Trail,West Barnstable Owner: Donald and Velia McCorrison Date of Inspection: April 22, 1997 TIGHT OR HOLDING TANK: none (locate on site plan) Depth below grade:_ Material of construction: concrete metal FRP Other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert- at outlet invert Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) Few solids in sump No evidence of leakage in or out of D-box PUMP CHAMBER: none (locate on site plan) Pumps in working order, (yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) i� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 93 Capes Trail,West Barnstable Owner: Donald and Velia McCorrison Date of Inspection: April 22, 1997 SOIL ABSORPTION SYSTEM (SAS):_X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods). If not determined to be present,explain: V Type: leaching pits,number: I leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) No evidence of surface ponding.breakout,lush vegetation or any other sign of hydraulic failure was observed CESSPOOLS: none (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert- Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY:none (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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 93 Capes Trail,West Barnstable Owner. Donald and Velia McCorrison Date of Inspection: April 22, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references,landmarks,or benchmarks. locate all wells within 100' LOCATIONS SYM A B C EACH 1 12' 6 PIT 2 15' 12' 4 SEPTIC 3 19.5' 17 TANK 4 30' 27* D BOX- 3 2 0 0 g A D C 4 BEDROOM DWELLING . #93 CAPES TRAIL NOT TO SCALE DEPTH TO GROUNDWATER Depth to groundwater:�0 feet method of determination or approximation: Comparison of USGS topographic mans and surface water elevation data TOWN OF BARNSTABLE LOC:ATIO43 -e--j 11L SEWAGE # VILLAGE Lj e.s-t' l s 4 SSESSOR°S MAP & LOT S ,INSTALLER'S NAME & PHONE NO. 01.,? Soc,a.u / EPTIC TANK CAPACITY a REACHING FACILITY:(type) p (size) r,G C-) �NO. OF BEDROOMS__C IV TE WELL OR PUBLIC WATER BUILDER OR OWNER B Ley 006k-r /L/,J-1 PS DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No & C- 06;� i) 5L5, , i/ 31.1 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Bi,spoii al Worko Tonstrurtiuu Prrutit Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System at: ' � I ....... oc•• C L -- -•---------------- --------•------------ • .---------------•------------------.----- ddress or I • o. . + .. Ovin�e��.�y (� t a ......................��-..c�V 1]'lSv�._.------- . �-=-=»'��� .... dress Installer Address Type of Building Size Lot_.��.A _d -.Sq. feet a Dwelling—No. of Bedrooms........... .......................Expansion Attic ( Garbage Grinder Qa a ,Other—Type of Building _____----.T"...._._.... No. of persons...._ ............... Showers () — Cafeteria Other fixtures .---.....••-• •---•-•......--•-• _ � MVZ1 ----------------••-•----------------.------•-----------------•-----_---....------------ Design Flow_._......__ .....................gallons per n p0 W e ay. Total daily flow--- ....................._gallons t WSeptic Tank—Liquid capacity_ !;� gallons Length_...e� ... Width.�..�__. Diameter-- Depth..`5i__�°ti. x Disposal Trench—No. ............... Width......... ...... Total Length........-`'..... Total leaching area------=........sq. ft. Seepage Pit No--------I------------ Diameter..... Depth below inlet..3d`�_. Total leaching area_._C�.L..A'.-�..sq. ft. Other Distribution box ( &e-r Dosin&`anl Percolation Test Results Performed by.......----------------------�--------_-_-----_ Date_...... .1.__.__-_-. Test Pit No. I.4!t:; .__.minutes per inch Depth of Test --------------- Depth to ground water_._ ..:o.. WV 4A Test Pit No. 2................minutes per inch Depth of.Test Pit,................. Depth to ground water........................ a ......... --•-- --...._..-•-•------•--------•----....----•--------------------------------------- ---------------------------------•----------------------- O Description of Soil_? —`X�� _. L.00��:V: c 4S�L�-- xu `--------------- .• - -- ---------------•----•------•••-•------•-----••-----•--•--•----•--------....._-----......_.. 1---*---`��------ tv .�:cs� c •_ 8� u1.1 t C. 7 62b 0 d4c1cs) x ---••--•----•---------------•------•••••-------••••-•-••------------•----•-•••------••----••-----•------•-------------------••--••----•----•------•--•----------•--------•...-•-----••••-•--------•----- U Nature of Repairs or Alterations—Answer when applicable...._....................:...................................................................... ------------•---------------•------------------...-•--------•-------•-------------------.......------•--------------.........--••--•-----•-•-•-----•••--•-•-•-.--••••-•-••-•---•--•-••-•----------•--•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has beeXi iss�pq by the board�of health. ' Signed ------ - -- --- ---- ---- . ..... .., 011,/... . Dace � • Application Approved By ------------------------------------------------------------------------- Dace Application Disapproved for the following reasons- ------------------ ------------------------- ----------------------------------------------------------------------------------- ---------------------------- ---------------------------------------- - ------------------- ---------- ------------- -- ---------------...........................--------------------- ----.......--------------------------- /� Dace PermitNo. .... ? -------Ix --------_------------------ Issued ...................................................... .------------------.....---......----- ------. ---------- Dace No... �: f. t _ FEB r.l .............- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for B44p.a i al Work.6 (foustrurtivrt Permit Application is hereby made for a Permit to Construct ((/1000or Repair ( ) an Individual Sewage Disposal System at Len .�� �...--...�3��P,_._,..�a�."�_At cam:,..... .................................................................................................. ocatio Address or Lot No. ....................................... .. c , _....------•---------- --------------------•-------.....-----••--•-----•--.....---...........--------------.............. ` �, Owner c�dress a ....."ti.5 •L,-x l t A_T7_N(+-.'..............•----------...-•---... a_3_ !rz .l. .�f_� �W h1 i��A,w•t�_1-� C� Installer . ...•..- Address 17 U Type of Building ^� Size Lot._9``,_� b2..Sq. feet I-, Dwelling—No. of Bedrooms..........C'�.........................Expansion Attic ( Garbage Grinder (N�� aOther—Type of Building ...........-_"_..____.... No. of persons...._ ----------_____ Showers ( —) — Cafeteria (—) d Other fixtures ------------- - ----------- :-_-- ... ----- G Ulll'�!fi W Design Flow............/...n.....................gallons per pecadn per day. Total daily flow___ �� ...-_.................gallons. WSeptic Tank—Liquid capacity.Wd� gallons Length._...' Width.�A..1p�_ Diameter-_. n..... Depth.��-q.� Disposal Trench—No....... .......... Width...._...""_._... Total Length......... ...... Total leaching area......_".............sq. ft. Seepage Pit No........I------------ Diameter--------�,_s; ..... Depth below inlet.._3:`... Total leaching area..r). � %.sq. ft. Z Other Distribution box ( �„�" Dosin _tan aPercolation Test Results Performed by.. .'_.... 1 ________________`�.........._._....... Date.....! !.3� 4 ____.__. Test Pit No. l_4n_a.-:-._minutes per inch Depth of Test -------------- Depth to ground water_._4...�!`_N � 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .........•----------------------••••--•--••••••-••••--...••-•••....•••••.....-•-•••......--•-••.............................................................. D Description of Soil.©_-`� �....�?$6�_-k S c�Qsot L-- x --••-----••----------------------- -- v 'Z•�'..-_ „---- i.4 _�M_..eornazs S ��llp �i.1� �.... .47,d A 0E.-0! U)(2 ...,. w x •-••-•-•-•-•-----------------------•-------•------------•-------- ......................................-----••-----------..._..-•-•-------••------•-•------------•---•••--•-•••-•---•-•--•--•--••••••. U Nature of Repairs or Alterations—Answer when applicable.___............................................................................................ Agreement f> 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 Compliance has been issued by the board,of health. Signed ------E---------- ------- ------------------------------- -17 r------ � ------- 122 Application Approved B ��w , r�---..... ... -------------------------------------------------- -- 1 ..PP PP Y ........ 3 V Date Application Disapproved for the following reasons: ...---....'- ------------- -------------------- ---------------- --------------..................................... .... .. . ............ ... .......--.........------ ...........--- ---- .......--- -- ------ --....--------- --...--......... ------- -- -- Date PermitNo. ----?'/.......txa'r�----------------------_----- Issued ........-.-- --........................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Crer#tfira e of Tomlatia ire HIS IS TO�CERTIFY, That the Individual Sewage Disposal System constructed ( Vl or Repaired ( ) by r.,\- 5 ....... x-..ttt V lh.R U -------------------------------------------- Installer J at --t'°� -3-� _. ...... ....1 = ........ c ..._ .V\A ------------------------------ == 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. ..--..f q/...-�.�).,&-------------- dated .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE Q SYSTEM WILL FUNCTION SAT IS ACTO f. m /j d DATE----- -- -- ------------------ -- ---------�... Inspector ., N� y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q� /l TOWN OF BARNSTABLE No..Z.�:..x �/) Dismal Works %'_F41nstri ilan amif Permission is hereby granted-----.�-0 S---- X V°t V 1A1 U to Construct ( " or epair ( ) an Individual Sewage Disposal System at No."!:.•...1. ...........� C tf1 P r=� �� �l t .�_ ............... -•--••••----•-•-••-•-•--••••--.._...••.•--•-------------•-----••------------••-•-•-•-------•-----•-•-••----•-•--•-•-•--•......•---.... E.L"�t I Street p. ��� as shown on the application for Disposal Works Construction Permit No._✓✓✓_/+./.�_.__. _._ Dated.......................................... --------------------------- ; ?/-------------•--•---------------- Board of Health DATE--------------- --�-- ---� •----'--/-- FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS v �Illftf}IITTTTTTTT"1filffRT1!1(1TiI}TTT}ttT}r}T}ttTrrrTTnrrTrTTxntTTTttrrrTTrr}rrrTtrtrmTm TrrfrTTTTttt.......ttTTn.......TTTttTtTT.... TTTTT+.TmTrttm TTT ttitruTnnrn ,rrTTr ttt T+ ttrTrn r e Trrr rnTr :: :. .t.::.., . .T. .T. .:.:.: ...}. .1.,TT.. .. ,ftSTT,TiLT. 1f....a, ENVIROTECH LABORATORIES =_ Mass. Cert.#:MA063 ` 449 Route 130 Sandwich,MA 02563 • (508) 888-6460 = z = c_ CLIENT: Bayport Homes LOCATION: Lot 32 Capers Trail — ADDRESS: P.O. Box 80 _ W. Barnstable,MA _ - _. E. Sandwich.MA 02537 COLLECTED BY: Meehan Well SAMPLE DATE: 9/16/91 TIME: DATE RECEIVED: 9 16 91 SAMPLE ID: Z-387++ ` New Well 160 ft JOB +�: _ WELL DEPTH: RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 _= PH pH units ---- -- 6.0-8.5 5.86 3 z Conductance umhos/cm 500 320 Sodium mg/L 20.0 49.1 Nitrate-N mg/L 10.0 1.82 c' Iron mg/L 0.3 _ 0.33 r' Manganese mg/L 0.05 z Hardness mg/L as CaCO 500 >~: 3 Sulfate mg/L 250 » Potassium mg/L 20.0 _ Alkalinity mg/L 200 ; Chloride mg/L 250 c Turbidity NTU 5.0 E Color APC units 15.0 » Background bacteria Sodium is not a health hazard,but if on low sodium diet consult with COMMENT: =� physician before drinking. ' Volatile organic compound UG/L see attached report Below Reporting (EPA Method 601/602) Limit YYEEX NO WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS T STED. c ' DATE ...... . ... . f�lIUi1111111111!!l UlllillUUl illUll1111UiUlll Uil111111i1i111t11 illtl Ull tilllilliltiiilililliil amwl iiilUlliiillUiiiil111itilltlillill!lliilltlltllitlll►liiliii!ltillltl�' GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: Z-384 Lab ID: 1971-01 Project: Bay Port Homes Lot 32 QC Batch: VGA-387 Client: Envirotech Laboratories Sampled: 09-16-91 Cont/Prsv: 40ml VOA Vial/NaHSO4 Cool Received: 09-18-91 Matrix: Aqueous Analyzed: 09-24-91 PARAMETER CONCENTRATION REPORTING LIMIT (ug/L) (ug/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL 1 Vinyl Chloride BRL 1 Bromomethane BRL 5 Chloroethane BRL 1 Trichlorofluoromethane BRL 1 1,1-Dichloroethene BRL 1 Methylene Chloride BRL I trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL 1 cis-1,2-Dichloroethene * BRL I Chloroform BRL 1 1,1,1-Trichloroethane BRL I Carbon Tetrachloride BRL 1 Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL I 1,2-Dichloropropane BRL 1 Bromodichloromethane BRL 1 2-Chloroethylvinyl Ether BRL 1 trans-1,3-Dichloropropene BRL 1 Toluene BRL 1 cis-1,3-Dichloropropene BRL 1 1,1,2-Tvichloroethane BRL 1 Tetrachloroethene BRL I Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL 1 m+^-Xylene * BRL 1 o-M ene * BRL I Bromoform BRL 1 1,1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene BRL I QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS Bromochloromethane 30 31 103 % 83 - 117 % Fluorobenzene 30 30 100 % 87 - 113 % BRL = Below Reporting Limit. * Non-target compound. "Trace" indicates probable presence below listed Reporting Limit. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). '0. ' No.------- -------- 'ool Fee BOARD OF HEALTH TOWN OF BARNSTABLE ZppricationforlVelt Con5tructiquPermit ApKicat,on is hereb ade for a permit Co strut v), Alter ( ), or Repair ( )an individual Well at: - -- ! -- -=�_----------------------------------------------------------------------- ------ ---------- - Lo atio — Address essors Ma and P ce P c - -- -- - -- - ---- -Q� - -- = - Own r Address -------- ------- ----- ------------------------ Installer — Driller Address Type of Building Dwellings - Other - Type of Building No. of Persons--------------------------------------------------- Type of Well— - -: ---- - - Capacity----------------------------- - Purpose of Well------ ` `�'------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signe -----— - - -- --- -- --- d to Application Approved By - -- -� - - - -- -f - -- ------ - ----�-�--- dat Application Disapproved for the following reasons:----------------------------------- - - - -- - - — — — — - - - — -- -------------------------------------- date Permit No.- ----- - Issued ---- -- --- -- -- ---- - 1�a —e — BOARD OF HEALTH, '— TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CE&TIFY,1 That the Individual ell Co ucted (+<Altered ( ), or Repaired ( ) P bY----------------- - --------- -- -- --------- ---- --------------------------------------------------------------------------------------------- Inst ller at _ -3 - - -� --�----------�----a-- -------------------- -� - has been installed in accordance with the provisions of the Town of Barnstable Boa d of Health Private Well rotec o Regulation as described in the application for Well Construction Permit No.tdW__ P�_Dated--- --- � THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------- ------------------------ ------------------------------ Inspector------------------------------------------------------------------------------ No---------------------- Fee--r- -------- BOARD OF HEALTH TOWN OF BARNSTABLE 0[ppCication-*r Veir Cootruction permit Application is hereb}"itade fora p�gr�mit�to� Construcf`(v), Alter ( ), or Repair ( )an individual Well at: 6 Lo ation - Address Assessors Ma and P cel-. 6�,4 _ - - -_ -f d- x r-__- ' (2, . Owner Address r Installer - Driller Address Type of Building v Dwelling—1 - Other - Type of Building==----------------- No. of Persons---------______ Type of Well-- -- - -=— - -- -------------= Capacity---------------------— - —_-_- --— - — --- Purpose of Well-- Z)jjgz_A_.KAA-�— ---- -- 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.,= ___ '� -- ------- ,-- - - — �, — d/ante Application Approved By k�IW - C r date Application Disapproved for the following reasons:--------------—___ ,/t/ ;____—_ r J� (� date Permit No.------ - = Issued---S/ 14 1 1�-- --- --- -------_ —_____ r r r date -tt BOARD OF HEALTH -= `• ' TOWN , OF BARNSTAB LE m Certificate ®f Compfiantr THIS IS TO CERTIFY; That the Individ al Well Constructed (4, Altered ( ), or Repaired ( ) y- Installer �o� 3a has been installed in accordance with the provisions of the Town of Barnstable Boa d�jof/�H.ealth Private Well Protecttio� Regulation as described in the application for Well Construction Permit No �-r¢=— Dated-��!�--/=-! 7 T. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------------— ---- Inspector -- S � 1 � a e BOARD OF HEALTH t - r TOWN-_ OF- BARNSTABLE. - lVerr Cootruct ion 3peruut No. ---------- -----= Fee--- Permission is hereby granted —----------- , to Construct (k )",'Alter ( ), or Repair ( ) an Individual Well at: V Street as shown on the application for a Well Construction Permit 1 �� ---------------------------------------------------- Dated. -- / —-------- -- - Board"of Health, DATE ' s ACCESS COVERS MUST BE WITHIN INVERT ELEVATIONS : DESIGN CRITERIA : GENERAL NOTES : INSPECTION 9" MINIMUM. 6" OF FINISH GRADE PORT 3 ' MAXIMUM COVER INVERT OUT SEPTIC TANK: 97. 4 FIRST 2 ' TO DESIGN FLOW BE LEVEL MIN 2' OF PEASTONE INVERT /N )DIST. BOX 96. 97 3 BEDROOMS AT / /0 G. P.D. PER I . THIS PLAN /S FOR THE DESIGN AND CONSTRUCTION OR F/L TER FABRIC INVERT OUT D I ST. BOX: 96. B BEDROOM EQUALS 330 G. P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. �� lAM PIPE 3/4 " - i I/2- DiA. INVERT IN LEACH CHAMBER: 96. 73 97.4 96. 8T o DOUBLE WASHED STONE BOTTOM OF BLEACH CHAMBER: 95.9 NO GARBAGE GRINDER 2. VERTICAL DATUM /S ASSUMED. FOR BENCH MARKS GAS J/ 96 97 96 73 /O �$ 9 9 ADJUSTED GROUND WATER: N/A SET. SEE SITE PLAN. BAFFLE SEPTIC TANK REQUIRED: 3 OUTLET 4 HIGH CAPACITY INFILTRATOR OBSERVED GIROUND WATER: N/A CHAMBERS W/3.5 "+ STONE AROUND T 330 G.P.q. X 200x - 660 GAL. 3. ALL CONSTRUCTION METHODS AND MATERIALS AND EXISTING D-BOX BOTTOM OF EST HOLE .�1 : 90. 9 SEPTIC TANK PROVIDED: 1000 GAL . EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1000 GAL /0 'W x 38 '1 x 10-d SEPTIC TANK 6' CRUSHED STONE OR CONFORM TO MASS. D.E. P. TITLE 5 AND LOCAL COMPACTED BASE SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. DESIGN PERC RATE C 5 M l N/I NCH PROFILE .' NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE - 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0. 74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- N STANDING H-20 WHEEL LOADS. PRO V i DED: 4 HIGH CAPACITY I NF/L TRA TOR CHAMFERS W/3.5 '' STONE AROUND. A-460 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 460 S.F. x 0. 74 - 340 GPD APPROVED EQUAL . 6. SEPTIC TANK AND 0-BOX SHALL BE REINFORCED PRECAST CONCRETE OR APPROVED POLYETHYLENE. BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER WELL i TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE OUTLET, CATCH BA N _ 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE-. WELL 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. �/� FOR L OCA T I ON OF UNDERGROUND UT/L I TIES. h < 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE f DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION OF THE SYSTEM TO ALLOW FOR SCHEDUL /NG OF THE CONSTRUCTION INSPECTIONS. i 9. EX/S T/NG LEACH PIT TO BE PUMPED DRY AND BACKF/L L ED. SOIL TEST PI T DA TA I/ in INDICATES v INDICATES ' PERCOLATION OBSERVED TEST - GROUNDWATER h+ , SL •I P.12657 SL 02 LOT32 HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR / 1 0' 100.9 0' 100.9 44. 709+ S. F. FILL A SA ND 2/Ya / 12' 99.9 6 100.4 ,o ( A LOAMY IOYR B LOAMY IOYR \\ SAND 2/1 SAND 4/6 16' 99.6 40' ... .. ...... .. 97.6 D LOAMY IOYR C.I FIN£-MED IOYR ) �� p SAND 416 SAND MI TH 614 �• 1 \ 4? 97.4 � GRAVEL STONES A i y \� \ l SAND WITH 6/4R COBBLES 60 GRAVEL 7C 0 6 COBBLES NO WATER qo. NO WATFR 90.9 /fir BE��i, DATE: AUGUST 6. 2009 TEST BY: STEPHEN HAAS 1 -.f...97, _ O Oj„y'P�.� _ Wi;iVEJSGU tor: VAVIO JIAN/ON ee // 4 PERC RATE: ( 2 MIN/INCH BM-ON THRESHOLD if ff xi" EL-102.53 ck. / / TP.2 TP.I /f ` ! EXISTING i SEPTIC TANK WELL i i D-BOX ,'j`A 1 SC -- k x d 4 HIGH CAPACITY +i00.5 104_-.I NF I L TRA TOR CHAMBERS ? `:�: EXISTING PI T -5TONG AROUND GRND/BEAN P01 � OA C', \ 5 �r. OFF x CIVIL ►w' a i iW«3546 f S 7 / C SYST -/1// DES / G/V 9,3 CA P E-S T R,A / L "A P 8 8 PA R C E L / 4 wES T SARivS TABLE . "A . PREP �l RED >cOR cE �• LEGEND f ;.tom CB CONCRETE BOUNDIli/ / C 1,4 E M U RR ,4 Y -w WATER LINE SCAL E / - 20 SEP TEMBER / 6 2009 HYDRANT GAS L/NE N" { % & � '✓.' - ONW- OVER HEAD WIRES E �� G L E S U R V E Y I N G , I NC L OCUS \ L I GHT POS iT 9 2 3 R o u t e 6 A -E- UNDERGROUIND ELECTRIC LINE Y a r mo u t h p o r t MA 02675 -T- UNDERGROUIND TELEPHONE LINE %x i�� l \�� 5 O 8 3 6 2-8 1 3 2 CTV UNDERGROUND CABLEV/SION LINE k/ 506 4-32-5333 + 40.4 SPOT ELEVA4T/ON ` i f -40 EXISTING (CONTOUR 4(-IO PROPOSED (CONTOUR L 0CUS MAP o /0 20 4o FJOB N): 09-062 FIELD:CFW/EEK CALC: SAH/CFW CHECK: CFW DRN: SAH i �L _ .. :..�- :. _. :. -. • ,- .... x r...,:_.. ....:. 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