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HomeMy WebLinkAbout621&625 MAIN ST./RTE 6A(W.BARN.) - Health 621 & 625 Main Street/Route 6A, West Barnstable A= 132 - 013 - 001 13a-019- O7 Commonwealth of Massachusetts Title 5 Official Inspection Form r. �= 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 621 Main Street Property Address R,' William Cotter " Owner Owner's Name information is West Barnstable t/ Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information v25 33 on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 w Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey 1-15-2020 :.,,oma:zaza.m.n o.no:w.osm Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 s R Commonwealth of Massachusetts Title 5 Official Inspection Form j� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 621 Main Street Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System-Passes: ❑00 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. System services dwelling and shop. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. ' The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �- p Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 621 Main Street u Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I i 621 Main Street L:— Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 621 Main Street L Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] 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. ❑ E Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. El The system fails. I have determined that one or more of the above failure ❑ criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well l5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts F. ,p Title 5 Official Inspection Forma �= I11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 621 Main Street Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No Q ❑ Pumping information was provided,by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal,flows in the previous two week period? ❑ Q Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ a Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on; ❑ El Existing information. For example, a plan at the Board of Health. O ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 310 CMR 15.302(5)] t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l; 621 Main Street V� Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): see below Number of bedrooms(actual): 4 + shop NA DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Plans provided by the local Board of Health show design calculations for (2) 4' leach pits. Upon inspection leaching was found to consist of 3 flow diffusors with 3'6" of stone around. 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes F] No Does residence have a water treatment unit? ❑ Yes Q No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes RI No information in this report.) Laundry system inspected? ❑ Yes M No Seasonaluse? ❑ Yes a No See below Water meter readings, if available(last 2 years usage (gpd)): Detail: "WELL WATER" Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 � I c Commonwealth of Massachusetts �n Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 621 Main Street Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? A ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): t 3. Pumping Records: Owner- last pumped 1 month ago Source of information: Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts �n ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 621 Main Street v� Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 -1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Plan on file with town dated 1984 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2'3" Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): 105' from well to SAS Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection form iie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -- l ............. 621 Main Street V Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1'311 Depth below grade: feet Material of construction: K concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500gallons Dimensions: 1" Sludge depth: 35" Distance from top of sludge to bottom of outlet tee or baffle 0 Scum thickness Distance from top of scum to top of outlet tee or baffle NS - Distance from bottom of scum to bottom of outlet tee or baffle NS measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts �n ,p Title 5 Official Inspection Form Iel Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 621 Main Street Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form + �. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 621 Main Street Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): o„ Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 621 Main Street v Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms!in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ Teaching pits number: (3)flow diffusors 0 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. 621 Main Street Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Leaching showed no evidence of past back up when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert ' Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts 13— Title 5 Official Inspection Form P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 621 Main Street v- Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 621 Main Street V� Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately SkEICH OF SEWAGE DISPOSAL SYSTEM: Include ties to of least""o wrmanen!feiefenc:-S tar dmar 7r tx n{h Walks locate all wells within 100'd ocate whefe public water supply cor.,e} into house! C iyz✓> . I , i 5L I 1 L3 + Iawr, rc; sLls { . i a t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r-- c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 621 Main Street Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ■❑ Surface water ❑Q Check cellar 0 Shallow wells Estimated depth to high ground water: No GW @120"feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record 3-9-84 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form tSubsurface Sewage Disposal System Form -Not for Voluntary Assessments ............, 621 Main Street u� Property Address William Cotter Owner Owner's Name information is West Barnstable Ma 02668 1-15-2020 required for every page. City/Town State Zip Code Date of Inspection E Report Completeness Checklist- Complete all applicable sections of this form inclusive of: ❑� A. Inspector Information: Complete all fields in this section. 0 B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed FE] D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 o. � 8 _ TROY WILLIAMS V SEPTIC INSPECTIONS 4 d Certified by MA Department of Environmental Protection j (508) 385-1300 19 Hummel DriveSouth Dennis, MA 02660aCOMMONWEALTH OF MASSACHUSCOPY EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE HINTER STREET. BOSTON, MA 02108 617-292-5500 WILLIAM F.WELD Governor TRUDY CORE Secretary ARGEO PAUL CELLUCCI B. UHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM DAVIC mmi�ssioner PART A 1)14t#jv^ �rre4 CERTIFICATION Property Address: (0 4- 7. 6 H/ w ij-rn s S I t Address of Owner: II y„ti Date of Inspection: G /a G (If different) Name of Inspector: Troy Williams 6.21 ,e-— 6 1 am a DEP approved s tem inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) (,J - �o�r�-s Company Name: Troy .W i i a m s Se p t i c I.n s p e c t i 011 S � Mailing Address: 19 HLmmpl Drive_ Snuth Dpnnjs MA 02660 (50R) Telephone Number: 385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes — Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signatures �'�y� litJ Date: 1�6 �J 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: V I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass' section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Indicate yes,no,or not determined (Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. / (revised 04/25/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: `a l f 02 S /e 7 /� Owner: Is Date of Inspection: (o BJ SYSTEM CONDITIONALLY PASSES (continued) f /�� Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Al1/11 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 1S NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,( }� CERTIFICATION (continued) Property Address: " c;2- I + 2 s L Owner: l c v2� G- i- Date of Inspection: D] SYSTEM FAILS: You must indicate ei:!.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �'oZ t (' _-42 T G Owner: Jy;ti'lh Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes, No Pumping information was provided by the owner, occupant, or Board of Health. _V/ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or f as part of this inspection. t/ _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. ✓. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _VI/ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of p Sub-Surface Disposal System. ✓ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 • r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION Property Address: d t a Owner: S / A-k k„ Date of Inspection: C 1,2 (. FLOW CONDITIONS RESIDENTIAL: Design flow: S•5 3 g.p.d./bedroom for S.A.S. 44/0 = Number of bedrooms: 4/ i' 51-,,- Number of current residents: Garbage grinder (yes or no): N0 Laundry connected to system (yes or no): `/<S Seasonal use (yes or no): A10 Water meter readings, if available (last two (2) year usage (gpd): �i.✓ a- f�✓4/I Sump Pump (yes or no):_AtO Last date of occupancy: Qe-`-"io , z , COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if.available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPIN4 RECORDS and source of information: v 'P011 wt ., .4 A. . ­_ 4- i--e-w System pumped as 6art of inspection: (yes or no)i 0 If yes, volume pumped: gallons Reason for pumping: TYPE QF SYSTEM _V 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all llLl components, date installed (if known) and source of information: s // oA Sewage odors detected when arriving at the site: (yes or no) � (revised 04/25/97) Page 5 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) Property Address: b-2/ 7< S T 6 Owner: Date of Inspection: C /2 BUILDING SEWER: / (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: foncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: o/ �X /I k /s v Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 7 Scum thickness: /✓a Alm" Distance from top of scum to top of outlet tee or baffle: /10 S �'- Distance from bottom of scum to bottom of outlet tee or baffle: C. �+-+ How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) /0u T�� S �r ;� / w� �. -e--f "J r -!s . .,c w (,c- �.o o.� c h/d S i c '-r f GREASE TRAP: /V/1113 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (raviaad 04/25/97) Pago 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION (continued) Property Address: Owner: / Date of Inspection: TIGHT OR HOLDING TANK:/" //.;(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distributign is equal, evidence of solids carryover, evidence of leakage into or out of box), etc.) =yc C. Jc,- '7� Sn y' � GAY ✓ C V k.y C" /�- �a.r G ��,�p PUMP CHAMBER:_ (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.) L reviood 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION (continued) 6 Property Address: .), f b"'z Owner: 151 C4_ K Date of Inspection: l- /"?—G /� SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:,_ leaching chambers, number:," ��� ✓S 4-0--Is .,j leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number.-- Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) I (revised 04/25/97) Page a of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) !.M114 °�I 6lS - SNEO O`t yl 15' 30 ID F1 I "4j cc s (revised 04/25/97) Page 9 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �' t tG d S T 6 1 Owner: Date of Inspection: Depth to Groundwater " Feet — adjusted high groundwater level Please indicate all the methods used to determine High Groundwater Elevation: V/Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) use oy � �u h S �oLJG w t c + c,0 7 o .� ell' i3 �T�p h, o /mac. L. _ J (revised 04/25/97) Page 10 of 10 ;TION - SEWAGE `I �o>=e�T �. S A _ c> , J� GF��2IE�LE 8t_AcK Ar-. eje -SEPTIC TANK- - "D"8UX- -LEACH d ♦ N airT.',1 T' eF_r-nt�v� Ar-.Y U I..r'}JIThB_8 �rvxrcJtwi..Fe.k'_A f \, L o T /�Q,L..�` ,.� Q_ ♦ � .'y+oP �."-l-IMSII• D'!,T ia.�G.E. OP IQ h. <".Tvr.�•�:� ul'.CC_ �E Atfl Frt�. � TG n. /, C \ 4`S,Y AW YLY�.c.E.wm+ ' '•Cl+LSE S�+�G. 2'O•-'.a TO N" ` S.O�"I I�C f[, ��^\ �� � // I SJO__G `\ ���— -��--._'-•-. .-� �- r -- 1\� _ riff..-i \J- / �:`- .�- ;• _/ I`I'I -�..' E LCEV.J EEIEV. EIEV ELL "t--1 _. ', r T ,,,' ` �'•� ELEV. ELEV. / ' D.c: �,,, ....J .G-_- -� .. O I \ , T r1.�i �.—s:�:D.: , -ter. YJi7,!< _\ •r. 89 '�'3�..'� 3 \ S C.A. :ST HOLE LOG P a�s..11L. L Yf G4u0 1 -/ E1 ;¢tlin Rv �c,FA1RFiHtJK e. ES 1 ' q INITN SS.. LLI DAte L9 DESIGN BEDRDom HODS[ q9 ``��i �\ \� '�C ?p i� T.H. .'1 . �4.o T.H.� 2 �\ ..e •' � za�.Q(oe�ncs�-_ !' 1 Y- I \.�� , K7. .. ELEV. OG ELEV. ORl(fi['owTlL£•I L. �S itL�.S�S=G 1 .. 7 Z Dicr.USER DI' J��F. 1 _�.. J �' / PERC RATE Mlh!IN.. \ v: c.r Ecr..T.c•r; A }f ' Gc....y.`: -•� �:�It t• "' GA L✓DAV cc'�j -- \ ` CEfM1Pop�a crl.L v��4 FLOW RATE yy'.o t t ,j SEPTIC TANK 55 3 0•SI= Y�� J �L. �_4�� —= CV REO'D SEPTIC TANK SIZED Go - .\\ 14.n - J'�'j•'` i:EwCi•�M1TA.OI.E i'-GG. I LEACH FACILITY e \_ �_ EI 14.5 .� 1 I �. -� I I `•"�"`�"� �� / 1 )I - SIDE WALL t! TT 4'140 7_K 'Sc•;5 L.S'1 �t'�- G/D.. w� a+..,. I z a u3 x i•Z34•' _22.6 1D - _-_jJ�o ... o c BOTTOM L4 (I.o 1 • G, . 1 '� !� ema<" Etc. I rnnr t :T.• "'l �[,J�,••c TOTAL I.Sd SbD.Z- �/i SL 1 .. i._l USE: Two 1-/ —LEA.CI-WAG �e.1�• 11- s L K 4' •>,o ...rr.t �"''•'^-- WATErVNCOUNTEREDo. 1. f OTES: (UNLESS OTHERWISE.NOTED) . od za-E / Z° y I.TUM IMSLI=-TAKEN FROM SAyDW/G� QUADRANGLE MAP .M•lI CIPAL HATER Z42S: i \ .. =E PITd1:1a^.PEA FOOT I:O . .�J� '1' 1 ��6�• �, ��3°(.00 -: -39.C,o" V '.:SIGN LOADING FOR ALE P REL AST UNITS'Aq*MO ~ "« •" ARNE H. —�D1 NCE AS CERTIFIED : 10�'IS -+, .r•N,OROEXiO C•OYEROVER'AI.I SEW qGE FAOIL�T IF3.(11 FT. - ,GG -r E101(Ri_tM,All 6E MADE MATE.IIO.T " •'. i .OJALA r^ �J1 oNiTgtiC7tdry�pETAll3 7p K:ACCORDANCE MiTH COMM.of yA15. - - CIVIL V [- I. �; I HEREBY CEiiTIF V.THg7 THE BUI IOING S PLAN ;I [EN��S"porgy Iwo,TpuLyl +�i s /Cipe fo .ws...cTlou �'•� 2 s r ON THIS AN IS LOCATED ON THE r. �T E^ PTE:-G A("0 E: Mr.I .. -.Q/`. o 5 b7 � � FUND AS SH HEREON - LLL ..{c :_r... -�s ����1b� WEGT•�A�N -TAl L.Ta,MP.S`; .) .• s .,�. S"� Am = REF j v a �a . baTE 1 w DE•ELI2RBETH EoLE l ..r. C dOWA tope `e�gineenng PREPARED FOR:, �V'M•l �.:,'� .. �• ':-qIF• a .a vt./H20 ) -,_'FIVIL ENGINEERS '\ .i-.•� „d ..t tw N .';Z .:� N� .. eoARO Qv w6•�1,7H - '. I:AND SUR V EYORS R „•-., / - .: .,. SUR. E J n 40 -A BQ- ,Y�IT) APPROVED STE •R N .-q MA YnmouerarlA �- DATE (IR DPOSEOI ', x BCAI TOWN OF BARNSTABLE LOCATION 6 c2-f ' Of(124 6 14) SEWAGE# VILLAGE �' � `� � ASSESSOR'S MAP&LOT 3 2"0 oWl INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1'500 LEACHING FACILrTY: (type) 3 (' (size) NO.OF BEDROOMS -f- S � H�L�1 9R OWNER "CE 1 Q-iNt4*-7 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet I Furnished by I Ile s � TOWN OF BARNSTABLE " 0 1 3 ® 00 LOCATION ('Da "�6�� G " SEWAGE VILLAGE "'"S �t ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) f"lo S (size) "'' 3 • "`_ NO.OF BEDROOMS Y*-S L.UP BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) (o Feet Furnished by TA- Fla�gc. L9 )o U „ a � bn U C- . SENDER: 'a ■Complete items 1 and/or 2 for additional services. I also wish to receive the w ■Complete items 3,4a,and 4b. following services(for an ■Pr n your ouro name and address on the reverse of this form so that we can return this extra fee): Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address ` permit. Receipt Requested'on the mail piece below the article number. d m at ev a' 2. ❑ Restricted Delivery N r The Return Receipt will show to whom the article was delivered and the date C C delivered. Consult postmaster for fee. 0 3.Article Addressed to: 4a.Article Number d a E ��— 6-4 4b.Service Type U l� ❑ Registered Certified 7��.� �Z 6 ❑ Express.Mail ❑ Insured Return ReceiptfFMonblike ❑ COD 7.Date of.Deli ery� w a 1 8661 p 5.Received By:(Print Na )) 8.Addresse-e's Addiess4(Only i q ested 19 u~i '/ Jj a r-f� G '^t'� and fee► i d) � � t 6.Sig�nnature: A ressee or Age t) q X `A! 0 PS Form 3811, December f 994 102595-97-B-0179 Domestic Return Receipt UNITED STATES POSTAL SERVICE(",'—© f 1 q O PI Sta {ess Mail-FUOTPaid P U PS M Permit - • Print your n met,6adifress, and ZIP Code-in t%s.box•�� PGblic Health Division Town of Barnstable PO Box 534 Hyannis, Massachusetts 02601 Fax(508)775-3344 . Phone(508)790-6265 I j F 1yy j } y} j a 3 498 568 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent&p G(� Street� /u G6 g�� c�incr�c� bz & h Post ,St ,&ZIP Code Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee Return Receipt Showing to Whom&Date Delivered o Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ wh Postmark or Date W rL Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached; and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m return address of the article,date,detach,and retain the receipt,and mail the article. Qw- LO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. 1 CO CO) 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. o LL 6. Save this receipt and present It if you make an inquiry, 102595-97-B-0146 a l i Town of Barnstable i i vs snxxsTeStE Department of Health, Safety, and Environmental Services y� MA3 03. ,�A TE39. Public Health Division P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A McKean,FAX: 508-790-6304 an,RS,CHO Director of Public Health September 2, 1998 Mr. Thomas Slaman 621 & 625 Main Street/Rt. 6A West Barnstable, MA 2668 NOTICE TO ABATE VIOLATIONS OF THE TOWN OF BARNSTABLE REGULATION REGARDING FUEL AND CHEMICAL STORAGE SYSTEMS Our records indicate that you have an underground fuel oil tank located at 621&625 Main Street/ Rt. 6A, W.Barnstable, MA. This tank is listed on Parcel 132 on Assessor's Map 003-001 and registered as tank tag# 740. This tank is not located in a critical zone of contribution to our public drinking supply wells but is 30 years old or older. You must have your underground tank removed within 30 days from the receipt of this order letter. For the removal of the tank you must first obtain a removal permit from the Fire Department. I have enclosed tank removal information for you. Upon removal of your tank, please return valve tag#740 to the Health Department. You may request a hearing before the Board of Health if written petition requesting same is received within seven (7) days of receipt of this notice. Sincerely yours, Thomas A. McKean Director of Public Health Enclosure: Tank Removal Information September 26, 1998 Dear Mr. McKean: Regarding your letter concerning the underground oil tank at 621-625 Main St. W. Barnstable, the tank was removed in 1990 or 1992 . The last time I was contacted by your office about this matter, I checked with Chief Jenkins at the fire department and he said he would send the information to you regarding the removal which he had inspected. I sold the property in September 1997 but I 'm sure the fire chief has the information you are looking for. Sincerely, Thomas Slaman 81 Warren St. Charlestown, Ma 02129 WEST BARNSTABLE FIRE DEPARTMENT i ♦ WEST BARNSTABLE, MASSACHUSETTS 02668 ♦ Cy �Z ,y. • ► February 24 , 1992 JOHN P. JENKINS FIRE CHIEF EMERGENCY 362.3131 BUSINESS 362.32AI Thomas A. McKean, Director Health Department. ..Town of Barnstable 367 Main Street j ,• Hyannis, MA 02601 4-1 RE: UNDERGROUND TANK REMOVAL NOTIFICATION Dear Mr. McKean, ' l This is to notify you of the removal of an und rground storage tank.- The following information is provided for your convenience. DATE OF REMOVAL: February 24 , 1992 STREET LOCATION: . 621 Main Street PROPERTY OWNER: Thomas Slaman TYPE OF TANK: 500 gallon steel, round PRODUCT: #2 Heating Fuel TANK REG. TAG: Town of Barnstable Tag #740 Chief Jenkins from this Department supervised the removal of this tank. The tank was solid, and there was no indication of Zany leakage from the tank. The owner has installed a 275 gallon tank in the basement to "replace the tank removed. No application has been made for :installation of another underground tank at this premises . To this Department 's knowledge, there are no other underground storage tanks on this premises . Sincer 1 yours, Joh Jenkins, Chief of Department .JPJ j P Mowol,4 No V V Z�G �d J��o Fee--- - BOARD OF HEALTH TOWN OF BARNSTABLE 2pplication,forVell Construct ion Permit Appllii aation 15 hereby made Vrmit to Construct ( ), Alter ( ), or Repair ( )an individual Well/at: Location — Addres Assessor Map and Parcel wner f Address Installer — Driller Address Type of B ing �p Dwelling--j��----------------------------------------- Other - Type of Building----------------------------- No. of Persons------ --------_____ Type of Well— — — ---- - Capacity------- — Purpose of Well--------- L - -- ------- 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 unt' Certi ' ate .o a has been issued by the Board of Health.. Signed - - ---—- — - — /7—6 — date Application Approved By-- �/P b -- — ---- ----------------- --- date ---------- Application Disapproved for the following reasons:---------------------------------------------__--------_—________—______—_ ---- --- ---------------------------- ---------—----------- -- —------- date Permit No. - Issued— -- ---" - - — ----------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS T t ndividual Well Constructed (4, Altered ( ), or Repaired ( ) bY- - � -- - ------- Installer at- -�Pl__ - - `�=----- - ------------------------------------------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. 8 d-Q�--Dated-�--l`0j* THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- - - - —- — -- — - - ----- -- Inspector--- - —------------------------------------------—-— - L � • W 2 oab— ---------- No:--------- -------d Fee-- BOARD OF OF HEALTH TOWN OF BARNSTABLE 0(pp[icationArVe1C Congtruction Permit Application is hereby m de for a--ermit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location — Add s Assessor Map �and PParrcel — Owner Address y ------- --- - ------------- ------------------ 641(� mac✓ ✓��T_ 2 c� = Installer — Driller Address / Type of Bui ing Dwelling -------------------—---------------------- Other - Type of Building No. of Persons- Type of Well— — �-�s -- -------------—---- Capacity-------- — Purpose of Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions df The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until_a Cert'.icate 0 Ii ce has been issued by the Board of Health. Signed --- — - - ------ — �� `�---�--------------- date - 4- 6S . Application Approved By-- - -- __-------------------__-_-- __- - ----------- date Application Disapproved for the following reasons:---------------------------------------_--------_—_______—______—_ -------------- --------------------- ---- -------------- n I- ---------------- date • Permit No. —D�i=b-3�------------------ Issued- -- ---``-- crate - - ---- ------------------- -----------------;_=------------------------------------- -------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Comphance THIS 4-7 T / 'a ,,li'ndividual Well Constructed (�- Altered ( ), or Repaired ( ) ------ - - - - - --------------------------------------------------------------------------------------- Installer at_; •? - ��- ------------------------------------------------------------------------------------------------------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection -.Regulation as described in the application Construction Permit No�� Q Dated 259- 4"08--- \ 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 - - Velt Congtruct ion Permit No. —ZGO �.3(p Fee--- ------- Permission is h reby granted-- _ -- -------------------—----------------------—-------- —- -- to Cbn7A'�' ct ), Alter ( ) or Repair ( a ndividual Well at: �� o� ----- � --�� ,� t ----------------------------------------------------------------------------------- Street as shown on the application for a Well Construction Permit No. -------—------— - Dated--- ---- -------------------------------- ----------- l, _ - Board of Health DATE------�'_-_`'�_ _�O �i t f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �'7 Date of Inspection: L A-2 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks y locate all wells within.100' (Locate where public water supply comes into house) h ( >` _ M� 1D} 62 S F1 C-,, sc,� • Y - s 3C- s46y` ( Lj ( t AUL TROY WILLIAMS fm SEPTIC INSPECTIONS LW Certified by MA Department of Environmental Protection (508) 385-1500 19 Hummel Drive South Dennis,MA 02660 \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS PWU DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 WILLIAM F.WELD TRUDY CORE Governor Stcretac� ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: ba f +G S /ZT 6 A W />-. s f..5 �t Address of Owner: . ��, „ 4 s S I,44, ti h Date of Inspection: lO2 �� (if different) Name of Inspector: Troy W i 11 i s m s 6 d 1 e 9" 6 I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 1S.000) (,�} /Su r�-s�e./z, Company Name: Troy Williams Septic I.nspectio.ns Mailing Address: 19 H tmmP1 DriyP_a 'South npnnis, MA 02660 Telephone Number: ( 5�-3-8-5=1.3-00 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses _ Conditionally Passes — Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signaturti: i1 r" � Date: /2 d 6' 2 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this' inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: V I have not found any information which indicates that the system violates any of the failure criteria as defined_in 310 CMR-15303. Any failure criteria not evaluated are indicated below. COMMENTS: Bl 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. In dicate yes,no, or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined',explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiitration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. "' ":. THE COMMONWEALTH OF MASSACHUSETTS S BOAR® OF HEALTH W ' -------------------- -------- OF................................_ lY ...... l� . liration for is as al Works Tonstrnrtiun ranfit Application is hereby made for a Permit to Construct or Repair an Individual Sewage pp y ( ) p ( ) 5 ge Disposal System t .......5ZG& ............................................................................I...................... Lrrltion-: Add r s or Lot No.@� ...........................J..................................................................... ...... ........KK ................................. Owner Address Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) 04 Other—T e of Building No. of persons............................ Showers — Cafeteria Q, Other fixtures ............................................ W Design Flow............................................gallons per person per day. Total daily flow............................................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-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date_..................................... aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------------------------------------- -... ------------------- ---••-----------•------------------- --------------•-------------•---.------------------------ 0 Description of Soil........................................................................................................................................................................ x x -----•-••••------•-------------------------•-----------------••••••--•-••••-••----•---............................................... ------------ ------------- U Nature of Repairs or Alteratiq s— nswer hen applicable..... A -------------------- ............ I.V.•-• .... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ued by the board of health. Application Approved .._... ..rowing 3 ......./.......... Date Application Disapproved theasons-----------------------•-------------------------------•--------------------•--•----------------- ••-•-••-••-••--••--••---•...............................•-•••..............-----•-•--•----•---•-•-....---•-••-••............-•--•--•------•-----••••••-•••-• ........................................... Date Permit No....................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. . .................OF................ Appliratilau for Disposal Works Tonstrur#iun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal systemt: ... --------------------------••-•--•-•--•----- ff� Lo. tion-AddrAss or Lot No. ......�.1�. ........................ _.......................................................-......-•- Owner Address pq Installer Address VType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.................._..........______.........Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building _ No. of ersons____________________________ Showers � YP g ---•----------------------- -----P--�- ( )--- Cafeteria ( ) Otherfixtures --------------------------------------•••-• •--•-------•-••---••---••-------...---••---•---•••----------- ....._.___. W Design Flow.............................................gallons per person per day. Total daily flow............................................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--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water_____________________--. Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ----------------------------------------------------- •............ •--------------------- ••--•---•--•••••------------------------- •----------------------- Descriptionof Soil............................ •-----------•----•---------..._...-------•---------------------------------------------- •----------••----------------....--------- W. U Nature ofgqRepairs or Alterati ns=Answer hen applicable.-. �� -----------••--•-••---- -c +' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1S 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. gned--...: 1112.t 11-1•-----•----- Application Approved ______"____ .- ..__________________ Date Application Disapproved r the owing reasons-................................................................................................................ --.......-•-------------•-----------•-------•---....-------------•--•-••-•------.....__..._._..:_..----------------------------t-----_..--------•-•---•-------------------•-•---•----------•--:::...--- Date PermitNo......................................................... Issued.................................I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... �rr�i�irtt#r u� f�II3u�t�i�urr CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by ------•-••---• --•-•-------- -------•---••-----•-•-•--•---•-----•-----------•---•------ -------••-----•____-•-•-----•--- ----------------------------•---------------- e Ins a er a een installed in accordance with the provisions of F - r o he State Sanitary Code as described in the . application for Disposal Works Construction Permit No _: ��" dated j, THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE s SYSTEM WILL FUNCTION SATISFAC OR . DATE.................................................az ...-�1�.. ... Inspector..-•---.... . =0.9�_./-••--------------------•----....._...........-•---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . 0017- No -_-. •-•••••-••- ..........................................OF..................._......••...... ..... ...---•-••-•---_.._.._•••__•-- $�) FEE ............. i �rrr I IV Ttaatstnulion rrutit Permission is Eby granted_ = -, `} .... .... to Construc o epair ( ` vi wa a Disposal System r. at No....... Street ra as shown on /ap/pfitifor Disposal Works Construction Permit Now .:______ Dated__________________________________________ .._..... ........_ .:- ------1------•------------------------•••--•••_••---DATE. Board of Health -..._. --------------------------•--•---••--•••••-•- FORM 1255 A. M. SULKIN, INC., BOSTON TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION r_-__--"'"'""'--OWNER AND INSTALLER INFORMATION FEW- ADDRESS: 625 Street Ml1P" NO PARCEL NO. 013.001 OWNER NAME: hizabeth F. Cole- VILLAGE: West Bitable INSTALLATION DATE: "" - BY: _ DDRES j--u.CERT. NO. r �� ' TANK INFORMA ON r14 LOCATION OFITANK: , 'CAPACITY 500 TYPE Sted AGE 'V9 FUEL/CHEMICAL He$ti= Oil TESTING CERTIFICATION C ] PASS C ] FAIL DATE`"""""` LEAK DETECTION C CHECK IF N/A TYPE/BRAND E 1 ZONE OF CONTRIBUTION C ] YES CX] NO DATE TO@E REMOVED FIRE DEPT. PERMIT ISSUED .. 0 ] YES C ] NO DAT LUNSERVATION �' CX7 CHECK IF N/A DATE t BOARD OF HEALTH TAG NO. [ J C I[ J C J DATE / ►t f `L'` PLEASE PROVIDE A SKETCH SHOWING"THE-TANK- OCATiON ON THE BACK OF THIS CARD`rf I ) ° 5 0 �`6a5 M9w sT M9/N VTR�T COUNSELLORS AT LAW VARNUM TAYLOR(1909-1979) THE LANDMARK CHARLES MACKAY GANSON(1908-1982) 160 FEDERAL STREET WM.GARDNER PERRIN BRADLEY RIDGWAY COOK SIXTEENTH FLOOR CHARLES R O'CONNELL BOSTON,MASSACHUSETTS 02110 JOHN A.LEITH SUZANNE BROWN TELEPHONE:617 951-2777 ROBERT W.BELL FACSIMILE:617 951-0989 OF COUNSEL: JAMES D.COLT EMERY RICE September 9, 1988 Donna Miorandi Town of Barnstable Health Department P.O. Box 534 Hyannis, MA 02601 Dear Donna: Please find enclosed the underground fuel tank registration form for 625 Main Street in West Barnstable. I have diligently _ tried to ascertain who installed the tank and have not been successful. 'l have been told., by the. sula ul- he fu mer viroiier -of - the house (the former owner is deceased) that the tank was installed on or about 1965. We do not have any documentation, however, to back this assertion up. I have sent a letter to John Jenkins asking him for a copy of any permit that he may have in his files (my letter was sent on August 18) however I have not heard back from him. I am making arrangements to have the test hole prepared at the premises. It is my understanding that you will issue a tag upon your receipt of the enclosed form. Kindly send the tag to my attention at the address shown on the letterhead. Thank you for your efforts on my client' s behalf. Very truly yours, p J hn A. Leith JAL/dg Enc. CC: Elizabeth F.- Cole, M.D. BA °f Rasa BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE 0 BARNSTABLE, MASSACHUSETTS 02630 J 0 I 0 A1A55 PHONE:362-2511 EXT. 330 LAB 337 CLINIC 340 Elizabeth Cole NAME DATE TESTED 10/21/88 TANK LOCATION hp5 Main Street W_ Rnrnntahle 23 none resent TANK AGE TAG # P CAPACITY 500 Thank you very much for participating in our program to test underground storage tanks (UST) by soil gas analysis. The free test was offered under a grant the Barnstable County Health & Environmental Department received from the Environmental Protection Agency. I Because the use of soil vapor monitoring for UST system release detection is very recent and only limited information and experience exists with using vapor sensors in this manner, we can _ nn-_t gua-rantee that your tank has !-sot leaked . - However, our tests _ did not indicate an problem. You should also realize that a "good" result from our test is no indication of how long the tank will remain sound. If you ever decide to remove your tank, it would help our work if you notified us so we could take a look at it after excavation. This method has been given an interim approval for 1988 by your Board of Health. Depending on results of research this year, complete approval may be given, otherwise you may be required to pressure test your tank to keep it in service after 1988. A copy of this letter has been sent to your Board of Health and the records reflect that your tank test indicated no problem. If you have any questions, please contact Charlotte Stiefel at 362-2511 extension 334. NOTE: To prevent possible contamination of your monitoring well with oil or other substances, we highly recommend locking or covering the well . XC: Board of Health - Barnstable SECTION'- SEWAGE - _ 4 o. 3 — SEPTIC TANK — — "D" BOX — — LEACH IT '� \ tV wo ih �9+ gt rTOP OF FDN dr - . iMovrG ArvY u w q � I' :3aoP 30 � A Q t !} . - • (MSL)e Qpr Ca {Y. AzGuL.4t> G*aTtzr-_ f I.Q.ALri 'I�tTS .,2.,OF'187 ;h.. �• �1 •^,,,, -%..- A '-1'• Nri 9fs 3't.4 AI.+D ZapLA.cF_ WIT1�i Ct.gN.►s CGA�'SQ S�uO. / WASHED STONE s5 G "l /IA c fi •c, � � r• .` 4!s I N» OUT• IN+ G --- pr•+e/ �" ) / \�'•. / /' ISC7G7-G OUT»<�� N• [(T � e4•� ' ^ 2"9'1�' Z E. O' no SEPTIC TANK ELEV. ELEV. ELEV. � � �. I � 34 ELEv� -4 -1 e c ELEV. ELEV. �'S`o• �_ _ ZZ S.G . a WASHED STONE 1-7.2- .,. u.S.G S.A TEST HOVE LOG TEST BY"RF_3ti2.ZAmX,,pe_- 3,B WITNESS a4III�. N o•- rFA�e�} P n+ � .�� '� � � � � \ � � ✓{y � +{ TEST DATE 3� DESIGN S4` �.4 `� ��_ �, 1i 5 BEDROOM HOUSE ( ` r t / T,i-I. � 1 T.H. # 2 / -4- sr4vp (ae� oF•F'1c_c.11.q.© �P,S F.J4 WAT�.aZ_. «( J • `� ..J[O•S \ �(• oGa" ELEV. cac��� ELEV. O�F'F-1GCz OR 1t=,Q?P 6.=PD� STC'tL..I 1 Soo �, 1.5*), 1 I � �. •• oo .J win yott; Z DISPOSER DISPOSER ! `s- AL yl \ ,/ PERC RATE MIN/IN. �- G s_ v ZZIP 34.ti FLOW RATE (GAL./DAY) r�3+ 4 V•o �Z F3a D �t 1.. " SEPTIC TANK 553 fl.5)= L �' ! �---(Co� e''"" +,.`� r'I N REO'D SPTIC TANK SIZE I . r. s T iF LEACH FACILITY Y _ �► l � rn.- 19.5*: Z`; ,5 SIDE WALL 4!z)TfC¢ {SoXZ;3Df�L.�' _ �I�¢ G D. HAR +iiy, 12. '•�• aI s2Ilo� ' l � I i - ,�°� � M►x n w rT,� � �.M BOTTOM �4 )'�K 7- ( 1.0 ) Z2.(o G/D. ) 1 In-I r )1.. I TOTAL = 5 L"I,'�d = 9 SD.2. G f p. \ JL Ai 1 S\ ( f ;oc. �'. 2 USE: LEACHING wt�' �� w�ei +dKI mr�. �✓a UJ %Acrm. WATER ENCOUNTERED IZr � � X 41 Et'f• elnP+l, V/ ✓ I �� /,�.''.' L PAa 'E i�lhtCa 4 � . NOTES: (UNLESS OTHERWISE NOTED,) c�ez; I. DATUM(MSL)+_TAKEN FROM SA......7v.A1Gt.. 5u ,."QUADRANGLE MAP 2.MUNICIPAL WATER-_._! e+ ...........---AVAILABLE �� 3..PIPERITCH rk PER FOOT Z4" r(aw �t, � �it 4mor , 3� �7'DESIGN LOADING FOR ALL.PRE-CAST UNITS: AASHO-_ Qq44 .4 5,MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. C t ,`' -�--- Dl NCEASCERTIFIED.6.PIPE JOINTS SWALL 8E MADE WATER TIGHT JALA � ARNE H. 7.CONSTF2UCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. ���+�c- STA'T'E ENVIRONMENTAL CODE TI"T'LE 5 CIVIL � 1 HEREBY CERTIFY THAT THE BUILDING .___, ,, SITE pl AN lt, �4mp-t Q l,f,114 CGND1'Fk7�IS.,•I�'s' R,'!'•4� t 'Flow--rb 'eow�-t�yG1'101J. , lS..T '. . •. �+ 4,w ��1 ��j, � v t '� �pq �i';• � SHOWN ON THIS IS LOCATED T_HE_ bq t'y 4" 'l0•�a t * GROUND ASSHnWNHERFQN: .- � LL2CUS;`J_�•F���r . _��GA(tfi�,t� S� t k cr Qr W E S-T R 2 FJ S�f"A BL: ytl REG. O, GINEER DAT .�}�� rat `►, P�{} 12.ci` y'l,5 1*!r+e y"t J' -`i `J'+ R EF down re @nfn �r,,nA ► +� Pt3E1�AREDFOR: t? �� A # C<ot.E CIVIL ENGINEE $ F3 ' - n*R(4' Y. ti I BOA 1 LAND suR'WEY017f3 5 � . .p..1�}.....M.. ' r a _-�•^-_--(EXISTING) :,-. '�-�q. BOARD O> WEALTH R tf f r CONTOUR$ '(PROFpOs[D)• -o -O•-o-o- APPROVED OA>1TE ►`� A': +. -ter, '�'IM SCiAI.£ .,..�.. / s — ----- rt: » AAA Y�ilstduth� �� ATE } • , 4.M zu