HomeMy WebLinkAbout0047 MAGGIE LANE - Health 47 Maggie Lane
West Barnstable
A= 217 049
I
i
I
t Commonwealth of Massachusetts
Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for �\Y Voluntary Assessments
\a 47 Maggie Ln �
Property Address —
John Peterson _ rx
Owner Owner's Name F'�
information is 01
required for every West Barnstable Ma 02668 5/11/15
page. City/Town State Zip Code Date of Inspection Oz�
1'3
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 A. General Information filling out forms on the computer,
use only the tab 1 Inspector:
move
key to
cursor-do not Michael DiBuono
key the return Name of Inspector —
Y
DiBuono Sewer and Drain
,8a Company Name
8 Johns path
Company Address
PN°^ S Yarmouth
MA 02664
CitylTown State Zip Code
508-364-9587 S113522
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 A-p=ving Authority
5/15/15_
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.
5
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
Title 5. Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47_Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable Ma 02668 5/11/15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:•
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system contains a 1500 gallon tank that is seven ft below grade. A concrete Distribution box. All
tees and baffles are in place. The leaching is made up of two leach pits. The leach pit volume is
capable of handling and is the equivilant to a 4-bedroom,system Second pit was added in 1'992
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable' Ma 02668 5/11/15
page. Cltyrrown 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 j!
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):.
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with-310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
!Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable Ma 02668 5/11/15
page. Cltyffown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and:environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 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
47 Maggie Ln
�M
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable Ma 02668 5/11/15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ �. Required pumping more than.A.times Jn the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable Ma 02668 5/11/15
page. CityfTown 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 4 4.
(design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official l nspecti®n ®rrn
Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable Ma 02668 5/11/15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system contains a 1500 gallon tank that is seven ft below grade. A concrete Distribution box. All
tees and baffles are in place. The leachin.g..is..mad.e..up of two leach pits. The leach pit volume is
capable of handling and is the equivilant to a 4 bedrooms stem
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use?
❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)): 24,000 32,000
Detail:
78 d
9 P
Sump pump?
❑ Yes ® No
Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
15ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
�M 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/11/15
page. City/Town State Zip Code " Date of Inspection
D. System Information (coot.)
Last date of occupancy/use: Date
Other"(describe below):
General Information
Pumping Records:
Source of information: Pumped in 2012
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•3113 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
°,M ,•'�r 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is required for every West Barnstable Md 02668 5/11/15
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:
23 years
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 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.):
System is vented throught the roof.
Septic Tank (locate on site plan):
Depth below grade: 7 ft
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gallon
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gallon
Sludge depth:
3"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
l
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM •'' 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5/11/15
.
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 24"
Scum thickness 3"
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was pumped in 2012 Per Bortolotti construction
Grease Trap (locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�M •''+ 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable Ma 02668 5/11/15
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.):
Tank is 7FT below grade. Level in tank is normal
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
El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable Ma 02668 5/11/15
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'.. Normal level.
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution Box is at normal level with.
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:
15ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Foram
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�M •y''e 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable Ma 02668 5/11/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits- number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No signs of carry over and no signs of hydraulic failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth -top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is required for every West Barnstable Ma 02668 5111/1'5
page. Cityrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments note condition of soil signs of hydraulic failure level of ponding, condition
( g y p g, on of vegetation,
etc.):
No signs of ponding or hydraulic failure.
Privylocate on site plan):
( P )
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°�M •'' 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is West Barnstable
required for every Ma 02668 5/11/15
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of
Y 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
15ins•1,13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
E
Assessing As-Built Cards }'age 1 O1'2
TOWN OF BARNSTABLE
LOCATION Y ✓��4L�1_S � P SEWAGE d+
VILLAGE (,t.� �tl,.v�..Ct-,�� ��,+—
ASSESSOR'S MAP & LOT(Xl Q
INSTALLER'S NAME & PHONE NO. ld 19C C'�Qi'��
SEPTIC TANK CAPACITY__" c a5� SS VZ0
LEACHING FACILITY:(type)
NO.OP BEDROOMS -15_PRIVATE WELL OR PUBLIC WATER-WO-It
BUILDEROP.OWNER^_Y',`� �. �
DATE PERMIT ISSUED:_`
DATE COMPLIANCE ISSUED: ^"ya
VARIANCE GRANTED: Yes •.No
Y�
ry
1���1 y:5til
I
http:/Avw%v.town.barnstable-Ill a.Us/Assessing/HMdisplay.asp?mappat=?17049&seq=1 5/4/2015
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 47 Maggie Ln
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable:` Ma 02668 5/11/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check-Slope,
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15+ ft
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: 7/11/83
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators installers - (attac
h h documentation)
❑ Accessed USGS database -explain:
You must describe.how you.established the high ground water elevation: .
Test hole data on plan dated 7/11/83 indicates NGE at 186"s
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments
47 Maggie Ln
�M
Property Address
John Peterson
Owner Owner's Name
information is
required for every West Barnstable Ma 02`668'' 5/11/15
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 CriteriaApplicable to AlI"System s)`compieted
❑ System Information— Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
15ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is West Barnstable MA 02668 June 11 2012 required for j
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
"t
Whhenen filling out A. General Information
forms p the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return p
key. Septic Inspection Services Co.
Company Name
189 Cammett Road
Company Address r�s
Marstons Mills MA 42648
RAM City/Town State ;;Zi Code
508-428-1779 SI 12855 t
Telephone Number License Number
B. Certification
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 Furth ,Evaluation by the Local Approving Authority
June 11, 2012 Job# 12-94
In ector'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-11/10 Title 5 Official Inspection F r :Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11, 2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Tank was scheduled for pumping following inspection. Overflow leaching pit showed no svidence of
saturation or surcharge.
l
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):
15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts l
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11, 2012
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11, 2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less-than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins-11/10 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
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11, 2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11, 2012
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is West Barnstable required for MA 02668 June 11, 2012
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)): N/A Well Water
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
l5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is West Barnstable
required for MA 02668 June 11, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Tank last pumped on 2/2/07
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed if known and source of information:
PP 9 P ( )
Overflow pit installed 4/14/92
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
8'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
7'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10.5' long x 5,8'wide- 1500 gal.
2"
Sludge depth:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is West Barnstable
required for MA 02668 June 11, 2012
every page. Cltyfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was at bottom of outlet invert and tees were intact
Grease Trap (locate on site plan):
Depth below grade:P 9 fe
et
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11 2012
every 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 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
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11, 2012
every 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
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for west Barnstable MA 02668 June 11, 2012
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: Two 6x6 pits,
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pits are connected in series, overflow pit showed no signs of failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 47 Maggie Lane
Property Address
Petersen
Owner Owner's Name
information is West Barnstable MA 02668 June 11 2012
required for ,
every page. City/Tow:n 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
42
/%, ,
67 \/\/\/\/\/\/\/\/\/\/\/\f\f♦/\/\/\/\/\/\/\/\/\/\/\ \/\/\/\/\
24
Front
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11, 2012
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
15+
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:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Low area at end of road is considerably lower than SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
17
t5ins•11H0 Title 5 Official Inspection Form:Subsurface Sewage g Disposal Po System•Page 16 of
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Maggie Lane
Property Address
Peterson
Owner Owner's Name
information is required for West Barnstable MA 02668 June 11, 2012
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
CERTIFICATE OF ANALYSIS
Page: 1
,y: Barnstable County Health Laboratory
vJ3, cfrt'•.`^' Report Prepared For: Report Dated: 3/14/2007
...ri S.
John Peterson Order No.: G0739760
4 Chatham Trace
Wilbraham, MA 01095
------------
Laboratory ID#: 0739760-01 Description: Water-Drinking Water
Sample#: Sampling Location: 47 Maggie Lane West Barnstable,'MA Collected: 3/13/2007
Collected by: Ken Brochu
Received: 3/13/2007
Routine
ITEM RESULT UNITS RL MCL Method# Tested
Nitrate as Nitrogen 2.2 mg/L 0.10 10 EPA 300.0 3/13/2007
Copper ND mg/L 0.10 1.3 SM 3111 B 3/13/2007
Iron ND mg/L 0.10 0.3 SM 3111B 3/13/2007
Sodium 4.2 mg/L 1.0 20 SM 311 1 B 3/13/2007
Total Coliform Absent P/A 0 0 SM9223 3/13/2007
Conductance 640 umohs/cm 2.0 EPA 120.1 3/13/2007
pH 7.8 pH-units 0 EPA 150.1 3/13/2007
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved By- ` �-4
(Lab ector)
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
03/15/2007 THU 15: 17 FAX'5083627103 Barnstable CTY HealthLab --- BARNSTABLE HEALTH 0001/001
I
`gym: CERTIFICATE OF ANALYSIS Page: 1
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 3/14/2007
John Peterson Order No.: G0739760
4 Chatham Trace
I` Wilbraham, MA 01095
Laboratory ID#: 0739760-01 Description: Water-Drinking Water
Sample#: Sampling Location: 47 Maggie Lane West Barnstable,MA Collected: 3/13/2007
I Collected by: Ken Brochu Received: 3/13/2007
Routine
ITEM RESULT UNITS RL MCL Method# Tested
Nitrate as Nitrogen 2.2 mg/L 0.10 10 EPA 300.0 3/13/2007
Copper ND mg/L 0.10 1.3 SM 3111B 3/13/2007
Iron ND mg/L 0.10 0.3 SM 311 1B 3/13/2007
Sodium 4.2 mg/L 1.0 20 SM 311113 3/13/2007
's
Total Coliform Absent P/A 0 0 SM9223 3/13/2007
Conductance 640 umohs/cm 2.0 EPA 120.1 3/13/2007
pH 7.8 pH-units 0 EPA 150.1 3/13/2007
1
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved By-
/(Lab `
ector)
3
i
i
i
I
i
i
I
I
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
-\ COMMONVVEAL;TH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.
DEPARTMENT�OF.ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL, INSPECTION FORIaA—NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATIO�VT
Property Address: V7
Owner's Name:
Owner's Address:
Date of Inspection;
Name of Inspect please print)
Company Nam i
Mailing Address:
MA
Telephone Numbe
`TI
CERTIFICATION STATEMENT -
.
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and-complete as of the time of the inspection.The inspection was performefl'b sed on m-- 07
training and experience in the proper function and maintenance of on site sewage disposal systems.I m a DE.I ,
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.00,0). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the.Local Approving Authority
ails
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 orb eater,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.
Notes and Comments
V
****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.
Title.5 Inspection Form 611512000 page I
Page 2 of l I
OFhCIAL INSPECTION FORM . NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM,....
PART A
CERTIFICATION (continued)
Property Address:
Owner: a—AJ00
,
Date.of Inspection:
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 orin 3.10 CMR 15.304'exist.Anv 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 a roved b the Board of Health P . PP , y ,.rill-pass.
Answer yes,no or not determined. Y N ND in the for the following statements. If"not dete( ) n rmined• Please.
explain.
The septic tank is metal;and over 20 years.old* or the septic tarok(whether metal or not)is structurally
unsound, exhibits substantial.infiltration or exfiltration or.iank'failure is imminent:System will pass inspection.if the
existing tank is replaced with a.complying septic tank-.as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available: .
ND explain:,
Observation of sewage.backup or break out or high static water level in the distribution box due to broken on'.
obstructed*p ipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with.
approval of Board of Health): .
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than:4 times a year du.e to broken or obstructed pipe(s).The system will
pass inspection if(with approval.of the Board of Health).:
broken pipe(s).are replaced
obstruction is removed
ND explain: 1
i
Paee of I I
OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAOE.DISPOSAkL SYSTEM INSPECTION'FORM
PART`A
CERTIFICATION(continued)
i_
Property Address:
Owner:
Date of Inspection: cog; ( p
C. Further.Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation bythe 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 heaithi.safety And the environment:
_ Cesspool or privy is within 50 feet of a"surface water
Cesspool:orprivy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. . System will fail unless the Board of Health{and Public Water Supplier, if any).determines that the
system is functioning in a manner that protects the public health,safety.and'environment:
_ The system has a septic tank.and soil absorption system(SAS)and the SAS is.within 100 feet of a
surface water supply or tributary to a surface water:supply:
_ The system has a septic tank and SAS and the SAS is within a Zone l of a.public water supply.
The system.:has a septic tank.and SAS and the SAS is.within 50 feet of a privatewater'supply well.
_ The system.has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply_well". Method used to determine.distance
"This system passes if the well water analysis;performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is.free from pollution from that.facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided tharno other
failure criteria are t iaRered. A copy of the analysis:must be attached to this.form.
3. Other:
3.
Page.4 of.11
OFFICIAL °INSPEGThON FORI'✓1--.NOT F:O:R VOI;IINTAR�' ASSESSIVIENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A.
CERTIFICATION(continued):
Property.Addr
ess:.
ft4l
Owner: p ezj6,
Date of Inspection:
D. System Failure Criteria applicable to all
systems.-
You must indicate"yes" or"no"to each.-of the following for all inspections:
Yes NQ
I/. Backup of sewage;,into facility.or system,component due to.overloaded or clogged SAS or cesspool
Discharge or pondin'of effluent to the surface of the ground.or surface waters due to an overloaded or
clogged SAS.or cesspool
Static liquid revel.in the:distribution:box above.outlet invert due to an.overloaded or clogged SAS or
/ cesspool.
V Liquid depth in cesspool is less.than 6 below invert or available volume is less than %day flow
Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s.).Number
of times pumped
Any portion of.the.SAS',,cesspool or,privy is.below high ground water elevation.
Any..porti.on 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 Lprivate water supply well.
Any portion of a cesspool or-privyis:fess than 1.00 feet but greater than.50 feet.from a private water
supply well with no acceptable water quality analysis,.[This system passes if.the welt water analysis,
performed at:.a DEP certified.laboratory,for coliform.bacteria and volatile organic compounds
indicates that the.well is free from pollution from that.facility and the...presence.of ammonia
nitrogen and!nitra:te,nifrogen.is equal:to or less than S ppm, provided:that no other failure criteria
are triggered..A copy of the analysis:must be attached to this form.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails..The system owzier should contact the Board of
Health to determine what will be necessary to correct the:failure.
E. Large:Systems:
To be considered a larger_system the system must serve.a.facility with a design flow of 10,000 gpd to 15,000
gPd•
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— _ the system is within 400 feet of a.surface drinking water:supply
i the system is within 200 feet.of a tributary-to a surface drinking water supply
— the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped
Zone II of a public water supply well
If you have answered".yes''to any question in Section.E the system is considered a significant threat,.or answered
yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat:under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner;should contact the appropriate regional office,of the Department.
Page 5 of I
OFFICIAL.INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTIONFORNI
PART'B.
CHECKLIST
Property A .dress: AZAO& A01,4-f
Owner:
Date of Inspection: ,.
Check if the following have been done..You must indicate"yes"or"no"as to each.of the following:
Yes. a
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 'affles or tees, material of construction, dimensions, depth of liquid,.depth of sludgeand 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&terms ined'based on:
Yes no
_ _. Existing information. For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)J
Page 6 of 11,
OFFICIAL INSPECTION:FORM NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE D'ISP,OSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM:INF.QRMATI OPd
Property A d'ressc
Owner
Date:of Inspection: t
FLOW CONDITIONS
RESIDENTIAL [f
Number of bedrooms(design):—. Number of bedrooms(actual).: n/
DESIGN flow based'on'31O.0 R 15.203 (for example: 1 LO gpd.x tt of bedrooms): TC �
Number of current residents.-
Does residence have a garbage grinder(yes or no):
Is laundry on.a separate:sewage system (y s or no);tif yes separate inspection required)-
Laundry system inspected e .or no): 0
Seasonal use: (yes or no):
Lao-
Water meter readings; if av Table(last 2 years usage (gpd)):
Sump.pump (yes orno)
Last date of occupancy: �� y
COMMERCIALIINDUSTRI vd``0
Type.of.establishment:. ;
Design flow(based on J.10 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):.
Grease trap present(yes;or.no);
Industrial waste holding tank present(yes or no):—
Non-sanitary waste discharged to the.Title 5 system(yes or no):-
Water meter readings. if available:
Last date of occupancy/use:
i
OTHER(describe):
GENERAL
NERAL INFORMATION.
Pumping Records Source of information: �/ `n�
�U &
Was system pumped as part of the:i spection(yes or no): Vd
If yes,volume pumped:: gallons--How was quan ity_pumped determined?
Reason for pumping: -
TYPE OF SYSTEM
—Septic tank,distribution box, soil absorption system
_SinQle cesspool
_Overflow cesspool
Privy .
_Shared system (yes;or no)(if yes, attach previous inspection records,.if any)
_Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be
obtained from 'system owner)
Tight tank: _Attach a copy of the DEP approval
_zother-(describe)l\ ?1i JAf �496 _
pp oximate age of all compo ents date inst lied(if wn) and source of info tion:
Were sewage odors:detected:when arriving at the site(yes or no):. Wo
6
Paae 7 of l I
OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARI'ASSESSMENTS
SUBSURFACE SE'WAGE:=DISPOSAL SYSTEM INSPECTI01V FQR1V1
PART C
SYSTEM-INFORMATION (continued)
Property Address: V 7 MA(A� ZAA,,c�
111j aq AAJI�f/W1011
Owner: '
Date of Inspection:'
BUILDING SEWER(locatz on site plan)�Vd
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
- Distance from private water supply Well or,suction line:
Comments(on condition'of joints, venting, evidence of leakage, etc.):
SEPTIC TANK:Yo�ocate'on site plan)
Depth below grade:ZLM 9 1
Material of construction:__concrete_metal_fiberglass Polyethylene
—other(explain)
If tank is metal list age:_ .Is age confirmed by a Certificate of Compliance(yes or no)::_(attach..a copy of
certificate)
Dimensions:A-)" k f.n' X J5
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3 44/
Scum thickness: 7S
Ij
Distance from top of scum to top of outlet tee or baffle: L
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments (on.pumpin2.recommen tions, i et and outlet tee or baffle condition, structural integrity, liquid levels
as elated to outlet invert, eviden e of leakage, etc.):
62,V,
GREASE TRAP:VL(locate on site.plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass____polyethylene. other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date oflast.pumping:
Comments (on' pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage;°etc.):
Page 8 of 1.1
OFFICIAL INSPECTION FOI2IV1-NO I'FG►R. UliTA K A SSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued);
Property Address: ( /-
Owners
Date of Inspection:
(1 . t a TIGHT or HOLDING TANKI� (tank must be pumped at time of mspectton)(loc.a e on.site plan).
Depth,below grade:
Material of construction: concrete metal fiberglass_polyetliyIenz other(explain);.
Dimensions:'.—
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)'.
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:/\/0(if present must be opened)(locate on site.plan)
Depth of liquid level above outlet invert:
Comments(note.if box is:level and distribution to outlets equal,.any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
PUMP CHA_MBER::A(locate on site plan):
Pumps in working.order(yes or no):
Alarms in'working:order'(yes'or no):
Comments (note condition of.pump chamber, condition of pumps and appurtenances, etc.):
f
Page 9 of 11
OFFICIAL.INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEW.AC-E DISPOSALSYSTEM INSPECTION`FORM
PART C
SYSTEM INFORMATION(continued)
Property Ad ress: V7 ,
Owner: � \
Date of Inspection: C ct
SOIL ABSORPTION SYSTEM. (SAS): (locate on site plan,excavation not required)
If SAS'not located explain why:
Type leaching pits,number:
-leaching chambers,number:
aeaching.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,
AkAAA
6�YIQZV�5-
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and confiauration:
Depths—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of.groundwater inflow(yes or no): .
Comments (note condition-of soil, signs of hydraulic failure,.level of ponding, condition of vegetation; etc:):
PRIVY: (locate on site plan)
Materials of constriction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc):.
9
Page 10 of 11;
OFFICIAL;, NSPECTIONTORM-.MOT FORNOLI1INTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOS:A:L SYSTEMM-INSPECTIOIti FORM
PARTC .
SYSTEM INFORMATION(continued).
Property Address:
Tom_
Owner:payl�/Jvj
Date of Inspection
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the;sewase 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.
U�
Co .1
c
Ina[ . cdlon
Paae 11 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property.Address: 7 7
a
Owner: &IJ
Date of Inspection
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
11
Permit Number: Date:
Completed by: Q"!o,&(
HIGH GROUND-WATER LEVEL COMPUTATION
�,J f
Site Location: �!/( / d` , Lot No.
Owner: /�'i� IGi C�'%/°i'�'`/ Address:
n
Contractor: Address: : �ir�° 5��•�V r
Notes: A�6
STEP 1 Measure depth to water table
to nearest 1/10 ft. .............................................................................. .Date
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: _
OA Appropriate index well................................:.....®�
OB Water-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to �ya
water level for index well ........................... f
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ......:...................................................................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) ..............................................................:..............................................
Figure 13.--Reproducible computation form.
15
Me
IF
50P fic 7ay X- F7
10/
TOWN OF BARNSTABLE
LOCATION 7 �l� c�l L �. SEWAGE #. 2 - 7
VILLAGE (it.c_ ����-�� �`"� ASSESSOR'S MAP & LOTA/
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) P(ze=c Pp i (size) L.-), t
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER—Z_4 �'►�vr"\c.n•`�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
4
� 6
i
yr
q7
iMpy
No......l.� 1. Fis.... .? ..........
THE COMMONWEALTH OF MASSACHUSETTS
3arnstsb4 BOAR® OF HEALTH
OF BARNSTABLE
�tgned
Apptiration for Diopoottl Works Ton.otrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (-�an Individual Sewage Disposal
System at:
............. .. ...: :"c5��;v` ...... V.... . .........------------ (,et ......................................... ................................
Location-Address or Lot No.
... --.... -y?�• St.��...---•-'.......................................................
Ownei Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms____....................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Buildiii ___ No. of persons____________________________ Showers — Cafeteria
G4 Other fixtures -----------_- -------------- - . .
W Design Flow..._.._'57-1.5_________________________gallons per person per day. Total daily flow------'33Q._______-__.__.__..._.__gallons.
44
Septic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------t------------ Diameter.....C_ ........ Depth below inlet___.�9__P......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------•-----------------------------------------------------------------------------------------'•........................................................
0 Description of Soil........................................................................................................................................................................
x
U -------------------------------------------------------------------------'-----------------------------------------------------------------------------------.........................................
W
x --------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable..__ (+E_S`L7 � .____0__-h- ..... ...........
...----- .. � -< �� pG-- ���S`� . _.... �-�:�. .......Gs_c?--- ---PIT----•--•-------•--------
Agreement:
ment:
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 beerl issued h the bo of health.
Signed ...... .... .. ...:.... - i `�
Dace
Application A roved B �✓ ......... �'�
PP PP y ------. ... . '�-3
Dace
Application Disapproved for the ollowing reasons: ..... ........................... .............. ....... ..... . .....................................................
..........--------------------------------------------------------------------
Dace
PermitNo. ....---Q`-'--..5-.�..3- -------------------------- Issued ------------------------ --...-----------........-------------
Daact e
i
py
................_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a31>, TOWNrOF BARNSTABLE
Appliration for Dtipnsal 3vnrks Tonstrur#run rautit
�ppl Eati'on is hereby mad4dr—a-Permit to Construct ( ) or Repair (\-)"an Individual Sewage Disposal
Systems
i
.............. r - "•.• )-�- •-•-u � �) �c.
.................. ..•---•-----.....---� .: �. ..
...
.........................
I:oca;pn-:Address or No
........ . ........................ ------- ------------._.:...................
Owner Address
a -C mac ...._. �.�. ...... ...........-�._0..... �a -c c c ��..............................
� Installer Address
Type of Building Size Lot.................... .....Sq. feet
Dwelling—No. of Bedrooms___.. ....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .................�....... No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --------------- --------------------------------------------------------------------------------------•--•--....-•--------•--•-•--------------------
w Design Flow......�:5.........................gallons per person per day. Total daily flow....... .�J........................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........t------------ Diameter...... ...... Depth below inlet......<.1_........... Total leaching area..................sq. ft.
Z Other Distribution box ( )_ Dosing tank ( )
aPercolation Test Results Performed by_.-- ................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit._..__..............'Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of.Test Pit---................. Depth to ground water........................
P4 -----------------------------
•.....
---.........
•...........
.----------------------------------------
---•--•-•----------•-----------
..........
•--------------
-
0 Description of Soil...............................................................................•-------------------•-•----------------------...----•---•---------------.......---------
x
-----...---------------------------•-•-------------••••------------
.-------------------------------------------••----------------------------------------------------------
...... ---------------
w
U Nature of Repairs or Alterations—Answer when applicable...._ ..... ..... ........
.......... �� l.A�t-e- =-.r( ........ P--1..............•---••---
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 Compliance has been issued by the boaf4 of health.
�.
Signed . C -... � .. " ------ .1. c ..Date
Ap
J plication Approved BY ° '`'w` .`
Dte
Application Disapproved for the ollowing reasons- --------------------------------------------------•--•----------------------.......---...........---....-----...---•------------------
-------------------------------- ....................------------....------------------...------------. --- ------------------------------------.......---------..I................--- ............. ----••--------------- .... ------ •.
Permit No. ......................... ..........................are................---------..»ate ----
..--------��-.-....1...� Issued
Dale
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
V .erttf irate of C omplianre ;
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( `-�--
by........................ ..r1.. 1�... ,/t..� ..�1..... �J�<. �_.
Installer
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. ........ /-- 7 ....... dated ...........:...................................
THE ISSUANCE OF THIS'CERTIFICATE SHALL NOT BE CONSTRUED-AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.¢ /
DATE..............................................-!-------------------------------------------� Inspector ...... I-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
qq TOWN OF BARNSTABLE
Na.,�l.'..�-7� FEE......
�� �-
Disposat Vorks Tunstrudion. ramit
Permission is hereby granted-------------; .l IZ .LO u 4.. ..........................................-........................
to Construct ( ) or Repair ( -)-an-Individual Sewage Disposal System
at No................... -••--- ...... / 41 , _� 4-t, �,
-•.........................-----------------:...------.......------•. ...............----------•-------.......•••--......
`Ali Street
as shown on the application for Disposal Works Construction Permit No..... .....-.3 Dated..........................................
Board of Health
DATE................................................................................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS ////
l
No........93_565 F�s.....e.
............. .......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Tt .l .. ........OF.......
'7 .
Appliration for Eliapusal Works Tonstru.rtiun Vormit
Application is hereby made for a Permit to Construct (1X_1 or Repair ( ) an Individual Sewage Disposal
System at a-
...Y .........�.�.ram......-- -•--------. .......... .................................... ..........................................--------•
Location-Address or Lot No.
:4..........Co A_;.r4- 4Aj-'....----•.................. ......................................•----------------------------------------............--.....
Owner Address
W ----149, ..................................................... .-----••-•--------------.....----------------•-............��......�.�-14 S feet
� Installer Address
Type of Building 3 Size Lot.-.. ---------_ q.
,., Dwelling—No. of Bedrooms......... W..........................Expansion Attic ( ) Garbage Grinder ''&f'
aaq Other—Type of Building No. of persons............................ Showers
YP g --------•------------------• P ( ) — Cafeteria
Other fixtures ...............................
< JP9 - --------
W Design Flow...........l--C-&.....................gallons pPr, teP...
ay Total daily flow y .gallons.il
WSeptic Tank—Liquid capacity 9Q allons Length. Width.�:'�... Diameter................ Depth._-'_
x Disposal Trench—N - -------------------- Width.................... Total Length.................... Total.leaching area--------------------sq. ft.
Seepage Pit No........._r:........ Diameter.......I_Z1.. Depth below inlet........ Total leaching area._0.7�'g...sq. ft.
Z Other Distribution box (`--� Dosing tank )
0-4 Percolation Test Results Performed b .._._.�,,�.,..._�_�1����_ � ��.__. Date__.71.�.����..
y j;;
Test Pit No.�!'.._.._.._Z_minutes per inch Depth of Test Pit.._L5Io...... Depth to ground water.:......................
Li, Test Pit No!T.4----_minutes per inch Depth of Test Pit....(a.b..... Depth to ground water.............
x ...---•- --- - - .........................................................
Description of S il_. -1 �� /.t -- ',Y�'?' ----�•..............(� 1
1 r_ i' ��
0
P................................ ..... ..........
0 Nature of Repairs or Alterations—Answer when applicable...............................................................................................
,�l�x� i «, lea ' Svc✓. .�... ........ ...... .........
Agreement:
The undersigned agrees to install the afore scribed Individual Sewage Disposal System in accordance with
the provisions of LITIE 5 of the State Sanitary de—The un ersigned further agrees not to place the system in
operation until a Certificate of Compliance has b is ued b e o rd of health.
Signed... ....15: !y !----------------------------------- -----
ate
Application Approved By..........,�.. � �...._ ............ 3
Date
Application Disapproved for the following reasons:--.................................................................. -------••••-----------••-------•-------
-------------•-••-------.............----••-- ---------------
-•----.....------------------------------------------------.
Date
PermitNo......................................................... Issued.......................................................
Date
No........ 3-S'S Flms.....tl. "......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... 1 f---.....OF..... �......
�-�.-' - .....................
Appliration for Uiipnsal Workii Tanstrnrtinn ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
................_...... ' /�z L.--et.-/`� ..----•-•-- --.....-•-•--------------•--•-------.�-- -----•------------------•-----•--•----------
• Location-Address or Lot No.
r a� ,..G !..j►�.ij.
Owner Addr ess
W ............................... ...••-----•----•--------......---•---•--•..........................-•-•-----------.... ..- -
� Installer Address A �
Type of Building 3 Size Lot.-_:J._11(__1)--0.--.Sq. feet
aDwelling—No. of Bedrooms.......... ..........................Expansion Attic ( ) Garbage Grinder '7,4Jl
p, Other—Type of Building .......................... No. of persons............................ Showers ( ) — Cafeteria
Q, Other fixtures ...............................,..
�}------•--.------
Desi Flow----•-•-•-------- - ��-r---4L-yy�------------------•------------ -
W gn 1 .....................gallons per pei per day. Total daily flow____._._._ ..w,,, ....gallons.
��
9 Septic Tank—Liquid capacity1.�_�?�gallons Length_I/__:&._r Width.]._: Diameter________________ Depth.."--
Disposal Trench—No- -------------------- Width..................... Total Length....................Total leaching area....................sq. ft.
Seepage Pit No......... ........... Diameter.._.._.L rr.. Depth below inlet..... ... Total leaching area..---�._5��...sq. ft.
Z Other Distribution box Dosing tank I(4 ) _
a Percolation Test Results` Performed b ...._. l_ 1.1_..Q 1�"! __ l �j Date...7/ ...q_.� _ ..
Y f . ...---•--
Test Pit Not_J.._ . __-minutes per inch Depth of Test Pit... . �2...... Depth to ground water........................
fz, Test Pit No� -:- ^:.minutes per inch Depth of Test Pit...&.'$--..... Depth to ground water........................
O , >-' ----.........................................................
Description of Soil....-- ...'?2........0 t_?�.. . rry� ...... -I -�-U .---•-'.. ....-.----Y tv z .... Yil .D
(xj r S7 P ►LR��n "?ilt�a t7 - .-�-------------•J-.1.1�t?-!�-•---�--c....................... 4 1 .._t,J C.�- ``
- -------- -- .............................................................................P.-Ij zz J.j�22L" ... ..........
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
A4jV-----.0.r1t x"b..-./ ...... ,►,�ve� .' ., '-------Ce X-"X-'--------QA1'4C y-'----•--.3----•. �` �Q�•� " /x1K1.0 .
Agreement:
The undersigned agrees to install the afore scribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Ade— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has Weil isue be bo rd of health.
Signed ]IJ!t jE �4 kart EL..... _....
Date
Application Approved By.....................49 t..-•-- ... ........................................ ....AF/-B0...------........
Date
Application Disapproved for the following reasons------------------------•----•-•--------=----------------------•----------------•--------------.................
.....................•-------•--...f•-----•---------------••••---...---------•-------------•-••--•--•-•-.-•--------------------------------------------------------------------•-----------------•--•---
Date
PermitNo--------------------------------------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(Irrtif iratr of Tontli ittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY------------------- .... ......-----------...........--------------------•---. ...------------------•---------
Installer
at...............=----•-•---............... . .....-....... --------- Lal��-........---------...--•--•--.............------
-has been installed in accordance with ieprovisions of TITLE 5 of The State Sanitary Code as described in the
ti application for Disposal Works Construction Permit No... s•G_S'............. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........................------------------------------------------------------- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........OF...........................................
N : �....1.�.. FEE. ................
�i��a��il nrk� C�nn��rnr�ilan �erntii
Permission is hereby granted...............4 �--
to Construct ) or Repair ( ) an Individuals Sewage Disposal System
at No.--------. -� ? _A •-•. -------------`---- ��4 �
- ...
Street
as shown on the application for Disposal Works Construction Permit No....... ............. Dated..........................................
-
• --.•.•-- Board of Health
DATE--------- ---------------------------------•--.
FORM 1255 A.-M. SULKIN, INC., BOSTON y
�-
No I—-----T Fee—-- -----------—
BOARD OF HEALTH
TOWN OF BARNSTABLE
Z.ppiication-*rVell Conotruction3permit
Application is hereby made for a pqrni to nstruct ( ), Alter (,/), or Repair ( )an individual Well at:
Location — Address Assessors Map and Parcel
�-env ash V - y�:M plc--- ..�
eC:- ------_ —M_ __ Address
//Ok I
- -------------------}------------------------ - - - -- - --
Installer — Driller / AddressAks
Type of Building
Dwelling— p ---------------------------------
Other - Type of Building------------------------- No. of Persons--------- —
Type of Well--1� �C-- �- ---—-— -- - Capacity-------------------------
Purpose of Wel ---------------------------------
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 Qjof,,.omplince has been issued by the Board of Health.
Signed --- -------------------------- --------------------------- � ----�
date
Application Approved By
-
- — — — — - — -- - ___- __ —
date
Application Disapproved for the following reasons:------------------------------- ----
date
�_Permit No.---- - - Issued-------------------------------------------------- ---
date
FBOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO CEARTIIFY, That the Individu 1 Well constructed ( ), Altered ( ), or Repaired (�)
by----- 0�` 'JCce.�,. `I_c,�e���fc_llc� --- �C °� `—'� - -- ---- —
Installer
at—�7
has been installe in accordance with the provisions of the Town of Barnstable Bo r Heal},f rivate Well Protection
/
Regulation as described in the application for Well Construction Permit N ---------Dated-- - ------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE—___—_ _____---- --- — -- Inspector— -- —----------------------
--------- --—--- -
VV D
No.-------------------- . Fee---------------------
BOARD OF HEALTH
v
TOWN OF BARNSTABLE
Application forlVeri Con6tructionpermit
Application is hereby made for a pe it to C nstruct ( ), Alter (vj, or Repair ( )an individual Well at:
�f 7 /►1 c,, e _ ,�.�J � 4 6 -----------------------------------------—-----------------------
Location — Address Assessors Map and Parcel
6eo/ GP ,osb Y Mct4 _ � ^�
-------------------------
--------------------- -=------------------------------
Owner T _ Address
_* ---------
SI N. �( -�( �`: /
i,.� e t i_•_ 3( • ,�o� �o,w /�� M_qa�'�---fie
- - - - - - ------------------ ------------------- ----------------------------------------------------------------------------
Installer — Driller Address 't
Type of Building /
Dwelling----k-o u_c--------------------------------------------
Other - Type of Building --------- No. of Persons---_-___--------------—_______—___-_-------
Type of Well--'/-/1)6- --- --------------------------------------- Capacity
Purpose of Well /-)-D--/t4'-S T=s -
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 ompli nce has been issued by the Board of Health.
Signed- � - ---------------------------------- -------9a -
j date
Application Approved By-- ---- -------- - --(-------------------------------------
date
Application Disapproved for the following reasons:--------------------___------------_-___-_-------------------------------------
-------------------------------------------------------------------------
date
Permit No.
- --- Issued -- - ---- -- - -- - ----- ---- .-------------- -
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO/CE/n /CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( -)
f/R C4 v� c l ! tie /I On �/�.1 �Sc7
Installer
has been installed in accordance with the provisions of the Town of Barnstable Boar eald� rivate Well Protection
Regulation as described in the application for Well Construction Permit N /."/-'-- . -----/--------Dated--------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE=------------------------------------------------------------------------------------ Inspector----------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Vrrt Con5tructioupermit
�j
0
No. ----- v------- Fee--��--------------
Permission is hereby granted --------___r�-A ��G r r `� f ( ��' - --
to Construaf ), Al ( ),or Repair (� Individual 1 at:
No. o----7�r
Street
as shown o/n�th)e(pplication .or Well Construction Permit �.
No.--- -L/V /_- -- ------------------------- Date ; --- -. ------
Board of Health
DATE------------i-r----__-�_ _;--- ---------------------------------
.^-' "'^-'^.mow.-•+a+--^.'-, --. -_ _ _.._. __-�—�_... ,.
20 MIN, ---TOP OF FOUND. — ------ ---- -------
EL. _
i 10 FT MIN,
n
- CONCRETE - -CLEAN SAND
4 SCH. 40 P
COVERS VC
PIPE- MIN. PITCH —cONCRETE
1/8 PER FT. , COVER
2" LAYER OF
4 CAST IRON I2" MAX. --- _ __ ,
E PIPE - MIN. PITCH S 8ONIE 2 WASHED
f 1/4 PER FT
z
FLOW ', LINE
I 0
E� — 87 _ _ — _
II MIN.
CL
DIST EL= w
LOCATION MAP BOX ° ° 0
3/4 - I/2` o ci
' WASHED STONE ' : o - a °b
i p lL J
PRECAST LEACHING -
GAL. -'
--- - _
BASIN OR EQUIV. I
SEPTIC
TANK
I Y PROFILE OF GROUND WATER TABLE EL.
SEWAGE DISPOSAL SYSTEM
_ NOT TO SCALE
DESIGN CALCULATIONS SOIL TEST
NIUMBER OF BEDROOMS ., _ _ . . . . . . . . . . . . GATE OF SOIL TEST
GARBAGE DISPOSAL UNIT- _
TOTAL ES WITNESSED 9
/J ESTIMATED MATED FLOW
•e�-:1 ;:� PERC4L AT , � �.,+ E _'_ ..-M;N /INC�a
GA
1. f BR./DAY x BR. j. . . . . . GAL
u. OBSERVATION HOLE OBSERVATION HOLE i
REQUIRED SEPTIC TANK CAPACITY... ;SAL _ __
4, ACTUAL l-'E OF SEPTIC TANK ".=—GAL. r ELEVATION .� r-ELEVAT=. -
L-EACHING A�1"r� REQUIREMENTSIlk
SIDEWALL AREA __ GAL./S.F,
LEACHING BOTTOM AREAGAL.1S.F.
CAPACITY ('BOTTOM S1 LL) . GAL,
.. � FEE WA
RESERVE LEACHING CAPACITY ... -' '. .� GALL =r 7 s
Y-
C
a ' +
ram..
> 4 .
a ,.
NOTES
. I 1, ALL WORT MANSHIP AND MATERIALS SHALL CONFORM
TO D.E.Q.E TITLE 5 AND THE TOWN OF
- -
,4-
RULES AND REGULATIONS FOR SUBSURFACE DISPOSAL
1 �
J SANITARY SEWAGE
v
Y W
^' 2.COMPLIANCE WITH ZONING REGULATIONS SHALL BE
°�+ '`" + DETERMINED BY BUILDING INSPECTOR OR BUILDING BUILDING SETBACK REGULATIONS PER BUILDING
INSPECTOR 1 ER
COMMISSIONER CTOR OR BUILDING COMMISSION
% t MIN. FRONT SETBACK
3.EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY _�• ,
THE SAME MIN. REAR SETBACK
��., ® , " `>'== r '� Z'_ I <'� I�,�:" �f� ✓.1.: 3 Ira MIN. SIDE SETBACK
l.. II. APPROVED BOARD OF HEALTH
M
f"
DA, AGENT
/ 4 PROJECT LOCATION:
�JS V APPLICANT
G v
L_
- GEN ) SCALE '. . DR. BY: DATE:
EXISTING SPOT ELE4A _ %, JQMO
JOB NO APPD. BY REV.
EXISI..ING CONTOUR
FINAL SPOT ELEVATIONS Q J O��c^ QA�, INC.INAL CONTOUR �`� �' ) !T• G:AR CH DRAWING
SITE
n SOIL TES_r L OC AT i 0 N ( /�' � �" / REG. LAND SURVEYORS- REG. SAN/TAR/ANS
r f
Y 1348 ROUTE 134 P. O" BOX 1263 N O.
.,.:
SCALE , ,, r ' EAST GENN1 S , MASS. O F i
I