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HomeMy WebLinkAbout0881 MAIN ST./RTE 6A(W.BARN.) - Health 881 MAIN ST. ,W.BARNSTABLE A = 156 028 u j - ,15 No. —W, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2(pprication for Mitpogal bpgtem Construction Permit Application for a Permit to Construct( )Repair O Upgrade( )Abandon( ) ,Complete System ❑Individual Components Location Address or Lot No. Q�! RT � Owner's Name,Address and Tel.No. �C�1,2i• /yluvr Assessor's Map/Parcel Installer's Name,Address,and Tel.No. C Designer's Nape,Address and Tel.No. ,CZa Fee1d J, ,4ae_y cJlee-LacR z/vc- 7)$C. eAiv. /y a%.f;4r? S eBq s E457' TA,906",rCA ,S Du..Ch a039 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow I/ gallons per day. Calculated daily flow y O gallons. Plan Date f Number of sheets / Revision Date /4W-!— Title Size of Septic Tank /SOo Type of S.A.S. Fie 4!0 Description of Soil AAA Nature of Repairs or Alterations(Answer when applicable) r/d go 6g,'/eel &eTjp.Z Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been 'lssucd by thi Health. e _p Signe Date Application Approved by Date - _ _/ / Application Disapproved for the following reas Permit No. - aL9 T Date Issued Y {. �No. I j Fee t ,-a Entered in computer: JHE COMMONWEALTWOF MASSACHUSETTS Yes PUBLIC. HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yication for ioogarpgtent Congxuctionerutit Application for a Permit to Construct O Repair(>Q Upgrade( )Abandon( ) Oomplete System .❑Individual Components Location Address or Lot No. j Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1 S14vt7 Installer's Name,Address,and Tel.No. / Designer's Narr}� Address and Tel.No. `t3orcSF'�t d S, i��,a�2t� 5e;e.uoc a Zvc- �� �A x .W17DWrC,01 f39 2- 77 �.. Type of Building: ' Dwelling No.of Bedrooms_1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building,`+ i No:. of Persons Showers( ) Cafeteria( ) i " Other Fixtures Design Flow 11 D gallons.per day. Calculated daily flow VVy d gallons. Plan Date 6 ? Number of sheets--'- Revision Date 44d E. Title " Size of Septic Tank /5-00 iType bf S.A.S. F/E' L, ,.Description of Soil r-e-e 00 Za,-) J11^ Nature of Repairs or Alterations(Answer when applicable) 4i'.Q -eel ePs3.02eal a; Y Date last inspected: } -Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi— cate of Compliance has been' by this B Health. Signed Date a _ Application Approved by '+ Date Application Disapproved for the following reaso . Permit No. Date Issued r ----- ---- --------------- --THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of ��ompriante THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(,y)Upgraded( ) Abandoned( )by / L� SA�i P C re .7 at / - 6 a n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated a ' Installer Designer C E V The issuance of this permit shal n yXpos a guarantee that the sy m wig u ction..as desk d. Date # i Inspector 1 — -------�--------------------------- — No. '— ': 59- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Diqu al *pgtem Construction Permit Permission is hereby gr ted to Construct( Repair Made( .b in on System located at Ff and as described in the aboveApplication for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:ConStruQfion dfust be completed within three years of the date of pe t. G Date: Approved by �►� _ \% a A Town of Barnstable P# Department of Health,Safety,and Environmental Services �VIE Public Health Division Date �`— 3�< r g Q, 367 Main Street,Hyannis MA 02601 enruaar,►erE, �'Ar t 6��►�� Date Scheduled ��. Time�� \0t �eO . GZj Fra� �� � ee Pd. Soil Suitability Assessment for Sewage Disposal . Performed By: '� 4-409.r C5 WitnesSed By: LOCATION&;GENERAL INFORMATION Location Address Q Q>4 ` Owner's Name l Address Assessor's Map/Parcel: 9 ,/ ,0,;;� Engineer's Name NEW CONSTRUCTION/t 7 REPAIR Telephone# O Land Use `;24G-5t�CJ'�A l I wt'�. Slopes(%) Jd=7 Surface Stones• , Distances from: Open Water Body ft Possible Wet Area loomft Drinking Water Well `1450 ft Drainage Way ft Property Line ft Other r _ft SKETCH:(Street name,dimensions of lot,exact location of test hole &,pert tests,locate wetlands in proximity to holes) LAL Parent material th to Bedrock I (geologic) O /� Depth Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater _........_........._............._......._...............-....•..........._......_.........................-_................................. __.... ... DE ERMINA ON FUR SEASONAL HIGH WATERTABLE Method Used: Depth Observed standing in obs.hole: D in. Depth to soil mottles in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# _.__. . Reading Date:.__ -- Index Well level--- Adi.factor___ AdjI G undwater Level . PERCOLATION;TEST Date. Lt+me Observation 4 Hole# Time at 9" Depth of Perc ` k Time at 6" Start Pre-soak Time C? + Time(9"-6") End Pre-soak 1"' Rate Min./Inch AN/ Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant I DEEP OBSERVATION HOLE LQG Hole Depth from Soil Horizon Soil Texture Soil Color Soil O er Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel L 10 y — 77 � woe !- T aZ. DEEPOERAIONHOLE H � Depth from Soil Horizon Soil Texture Seil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel DEEP OBSERVATION HOLE LO;G Bole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel F s +. i DEEP OBSERVATION HOLE I.OG Hole#; Depth from Soil H Texture orizon Soil Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel) t i Flood Insurance Rate Map: Above 500 year flood boundary No Y Yes ` Within 500 year boundary No Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us material exist in all,areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on 10 (date)I have passed the soil evaluator examination approved by the Department of Environ e 1 Protection and that the above analysis was perform d by me consistent with the requir d training,exp sea experi c described in 310 CMR 15.017 �f Q Signature Date 1]2, " ` nTOWN, OF BARNSTABLE �I Ltk;A'I'ION � / , SEWAGE # VILLAGE U)LSf ghL(;A Eli, ASSESSOR'S MAP& LOT U INSTALLER'S NAIVE&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: ( pe) (size) NO.OF BEDROOMS 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) "' Feet Furnished by I _, _ t __.._. .. .aa j�� �`� �� - � - � � � . . . .�: :� .. .h Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12: 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 and of the form. Important:When A. General Information filling out forms on the computer, s use only the tab 1. Inspector: Y move Y key to our p cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections Company Name PO Box 896 Company Address East Dennis MA 02641 Citylrown State Zip Code 508-385-7608 SI 3742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority , 06/16/12 � Inspector's Signature Date t The system inspector shall submit a copy of this inspection report to the Approving Authoritjr JBoard of Health or DEP)within 30 days of completing this inspection. If the system is a shared system of.'; has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submitbe 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•11110 Title 5 V.;.Omn Form:Subsurface Sewage Disposal System•Page 1 of 17 t•� Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668r 06/12/12 page. Cityrrown 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: 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 eAltration 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 FIND (Explain below): Mrs-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 P� Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System form-Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Bamstable MA 02668 06/1.2/12 page. Citylrown 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 mannerwhich 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 Lj,,lils•i ii16 Tide 5 Cii.ial'diSTWW,Tum,f ZutrsuYare Seirnge Dooml SI—stem.•Page 3 0 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12 page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,ifany) 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 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 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is West Barnstable MA 02668 06/12/12 required for every �Y page. C frown 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) Lange 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 It 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12 page. Cityfrown 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 NIA) ® ❑ 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? ® El information 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): 440 t5ins-11/10 TAte 50fficial 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 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No, Last date of occupancy: current Date CommerciaUlndustrial 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: a t5ins•11/10 Trite 5Official 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 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/use: Date. Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑" Yes 0 No If yes,volume pumped: gallons. - How was quantity pumped determined? Reason for pumping: TypeS of stem: Y ® 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Tide 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 881 Main Street ' Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12 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: 11/16/99 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.3 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): 0.8 Depth below grade: feet Material of construction: ® concrete ❑`metal ❑fiberglass 0 polyethylene ❑ other(explain) If tank is metal,list age: yearn Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal 3" Sludge depth: t5ins•1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12. page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 15" 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.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts H v Title a Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition'of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Modal 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 881 Main Street Property Address Seth Haight Springbrook Owner owner's Name information is required for every West Barnstable MA 02668 06/12/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. 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: - I t5ins-11/10 Tile 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 .881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12 page. City1rown state Zip Code Date of Inspection D. System Information.(cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ® leaching fields number,dimensions: 24'x24' ❑ 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.): This system has a 24'x24'fieldof stone with four pipes spaced evenly in it.There was no sign of popnding or failure in the stones. Cesspools(cesspool mustbe 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-11/10 Title-5Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form `s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every• West Barnstable MA 02668 06/12/12 page. Cityfrown 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 Ti to S Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 4 , Commonwealth of Massachusetts Title _5 Official Inspection Form GI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is West Barnstable MA 02668 O6/12/12 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) 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 V"7 o ;. f _ t5ins-11110 Me 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of W r Commonwealth of Massachusetts W Tithe 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12 page. Cityfrown 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: 20.0 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 groundwater elevation: USGS maps show an elevation of over 20.0 feet.0. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 � q l Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 881 Main Street Property Address Seth Haight Springbrook Owner Owner's Name information is required for every West Barnstable MA 02668 06/12/12 page. Citylrown 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 I t5ins-11/10 Trite 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 1.7 �l / �Il � — No.--------------- -- - Fee------ -------------- BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rl ti Cootruction3permit Application is hereby made for a permit to Construct (�), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owner Address ---------- -------- --------- ---------------------------------------------- Installer — Driller Address Type of Building Dwelling -`—------------------------ Other - Type of Building---------------------- No. of Persons------------------------------_____ 01' Type of Well--_--�� ------------------------ Capacity---------------------------- Purpose of Well-------- - —_— ------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed - -- � _Q-q5— date Application Approved By - — J-'---- Of-l _ date Application Disapproved for the following reasons: -------------------_________—__---_—_ date Permit No. ---- Issued—�-- -- -- ----— - date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) �Insta er at- � �/� ��� CJ'. ,t!p/r/s--—--- ----------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ---------_Dated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTIONN SATISFACTORY. �dnn DATE-- -f 7 - Inspector----------------------_—_ --_ NoGt/- / - ----- Fee--------------------- BOARD. OF HEALTH TOWN OF BARNSTABLE 2pplicat ion Ar W ell-Congtruct ion Permit Application is hereb made for a permit to Construct Alter ( ), or Repair( )an"individual Well at: Locagon+ Address Assessors Map and Parcel Owner n Address Installer Driller Address Type of Building Dwelling—— -- •J-{ - - Other - Type of Building— No. of 4Persons------------,------ ---=-------- 4 Type of Well YP 1- — ----------- Capacity — Purpose of Well ----— — ---- -=------ Agreement: The undersigned agrees to install the aforedescribed`individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed — -- date q Application Approved By _�. _-_'____ �` ''9 date Application Disapproved for the following reasons: --------=--------------------------=- ---- - -- -- ---- -�__� -__ - date Z t_ Permit.No. — Issued---- date "+ Yi!�Qi�tiYih'SAP:Te!sl.iN�iSti!tilbli±i9eLAPAPe+i!`�r.i4e►el6Tesola4alli9iTe9ina:l63iFaPA'�'a.liliKPitiliviPAwaPY9iSiKi !a!m!iai'eG162i7F+R6°�isOiei?iTaei"li4a!oHlATnF64ixAti?aV�i BOARD OF HEALTH TOWN OF BARNSTABLE C ertif icate of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired Insta er at---- �'� _a� �•�_13.2,��/.-- ---------------------------- -- ---------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -----------Dated---THE ISSUANCE OF THIS CERTIFICATE SHALL'NOTBE CONSTRUED,AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- Z____—__ — Inspector--------- lAlpoi'iiili�iPifi4APdVi?iCi®ititiPiliiiliPiRAtii6PdPibiPbP.iObP�iPiPi9i00liP3PiiP3PiPi46iliP506Mi0iPi@iPiPiPiPi2ili98Ri154Y!i'Ri/i!Vai4i4iti!wYi!4!$aii!6�i4igi4P4iS6�AY!idili'�a BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Cmtruct ion Permit No. ---_LL—!_ Fee_�5 Permission is hereby granted to Construct (/), Alter ), or Repair ( ) an Individual Well at: No. P'F/ - street as shown on the ap lication for a Well Construction Permit �y No.- / —___ Dated— _ ? —� —---- --------------------- - Board of Aealth DATE DATE: 1 1 /1 3/01 PROPERTY ADDRESS: 881 Route 6A West Barnstable,Mass. 02668 ------------------------ J� On the above date, I inspected the septic system at the above address. Th is system consists of the following: 1 . 1-1500 gallon septic tank. A 2. 1 -Distribution box. 3. 1 -leaching field. 24 'X24 ' Based on my inspection, I certify the following conditions: 4. This is a title five septic syste. 5. The septic system is in proper working order at the present time. 6. Leachfield was dry at time of inspection. 7. Pumped septic tank at time of inspection. ` Heavy scum and soilds layers were present. SIGNATURE:.d J. Name:-J . P . Macomb'er jr Company: Jos_eTh_P. Macomber_& Son , Inc , Address: Box 66 RECEIVED Centerville , Ma . 02632-0066 DEC 07 2001 TOWN OF BARNSTABLE Phone: 508-775-3338 HEALTH DEPT. THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • a�� Y Kp c\- COMMONWEALTH OF MA.SSACHUSETTS ' r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 881 Route 6A West Barnstable,Mass. Owner's Name: Kari Murray Owner's Address: 120 West Bay Road 5 Date of Inspection:1 1 13 01 Name of Inspector: (please print) J.P. Macomber Jr. Company Name:Joseph P. Macomber & Son Inc Mailing Address: P=O= Box 66 rpnteruille Mn 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that 1 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 ction 15.340 of Title 5(310 CMR 15.000). The system: Passes _ Conditionally Passes _ Needs Further Evaluation by the Local Approving Authoriry F ils d Inspector's Signature: 'qg ' Date: The system inspector shall s bmit 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 authoriry. Notes and Comments ""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 6/15/2000 page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 881 Route 6A West Barnstable,Mass. Owner: Kari Murray Date of Inspection: 1 1 /1 3/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D System Passes: 4 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 septic system is in proper working order at the present time. B. System Conditionally Passes: -Va One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. 416 The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ,L Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 881 Route 6a West arns a e, ass. Owner: Kari Murray Date of Inspection: 1 1 1 3 01 C. Further Evaluation is Required by the Board of Health: Vb 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: AXl Cesspool or privy is within 50 feet of a surface water 2D Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. u0 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 IQO feet b 50 feet or more from a private water supple well•'. Method used to determine distance 2 "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. ther: i 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:, 881 Route 6A West Barnstab e,Mass. Owner: Kari Murra Date of Inspection: 11 13 01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 1 ischarge 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 esspool ,4 �iquid depth in.c@sspeei is less than 6"below invert or available volume is less than '' day now equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number '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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply t e system is within 200 feet of a tributary to a surface drinking water supply 6 _ _ 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 W. 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. 4 Pagge5ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 881 Route 6A West Barnstable, ass. Owner: Kari Murray Date of Inspection: 11 /13/01 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,eluding 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 ? tl— Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. 1 _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) '111 CMR 15.302(3)(b)] 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 881 Route 6A West Barnstable,Mass. Owner: Kari Murrav Date of Inspection: 11 /1 3/01 FLOW CONDITIONS RESIDENTIAL �)L Number of bedrooms(design):- Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):.P Is laundry on a separate sewage system( es or no): I� [if yes separate inspection required] Laundry system inspected(yes or no): ,� Seasonal use: (yes or no): AV ,'/ � Water meter readings, if available(last 2 years usage(gpd)): r,(/Q�,�1, /,(�� J If well Water Sump pump(yes or no): A)D has notbeen taested Last date of occupancy: t in the last 12 months It should be done COMMERCIAL/INDUSTRIAL at this time. Type of establishment: 4 See pages 6A&6B Design flow(based on 310 CMR 15.203): d _ . Basis of design flow(seats/persons/sgft,etc.): mil Grease trap present(yes or no): Industrial waste holding tank present(yes or no):Ay Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): ��19 GENERAL INFORMATION Pumping Records Source of information: �1 Was system pumped as part of the inspection(yes or no): _5 If yes, volume pumped:/0Uga11 ns--How was quantity umped determined? Reason for pumping: aCj/yYl y� �,(//� �/S1 u�'S „ ) TYPE F SYSTEM ,J..-Septic tank,distribution box,soil absorption system "Single cesspool Overflow cesspool 45 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 Otained from system owner) /!!�p Tight tank A10 Attach a copy of the DEP approval Vk�ther(describe): �vroximate age of all component ,date install d if known)and source of information: �e0i /ice Were sewage odors detected when arriving at the site(yes or no): 6 I Pale 7 of 1 1 �. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 881 Route 6A West Barnstable,Mass. Owner: Kari Murray Date of Inspection: 11 /13/01 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron �'40 PVC,�/Q other�(explain): zd� Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage,etc.): Joints appear tictht.No evidence of leakage-The system is vented through the house vent. SEPTIC TANK: (locate on site plan) 9 Depth below grade: Material of construction: l4ncrete4,0metal,�fiberglass&Lpolyethylene /VDother(explain) J I If tank is metal list age:.l9 Is age confirmed by a Certificate of Compliance(yes or no):sl1d (attach a copy of certificate) Dimensions: /B Sludge depth: l� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: Q Distance from bottom of scum to bo m of outlet tee or baffle: How were dimensions determined: J 7ji>f i DYE �iYJS,De,a7 ism) Comments(on pumping recommendation , inlet and outlet tee or baffle condi(ion, structural integrity, liquid levels as related to outlet invert,evidence of:leakage,etc.): _ Pump tht- Reptic tank every 9-3 Inlet & outlet tees ,are in place!-The tank is structurally sound and Shnws nn evidence of leakage. GREASE TRAP; (locate on site plan) Depth below grade: Material of construction:,&concreteametalgfiberglass popolyethylene &Other (explain): 1114 Dimensions: X//9 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: W17 Date of last pumping: AIW Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present 7 Page 8 of l I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 881 Route 6A West arns a e,Mass. Owner: Kari Murray Date of Inspection: 11 /13/01 TIGHT or HOLDING TANK. A4ktank must be pumped at time of inspection)(locate on site plan) Depth below grade: /11 Material of construction:,4/14concrete4�9 metalAWfiberglass J/�polyethylene 41h other(explain): Dimensions: AIM Capacity: alions Design Flow: gallons/day - ' J, Alarm present(yes or no): Alarm level:_22,# Alarm in working order(yes or no):.,&g Date of last pumping: " Comments (condition of alarm and float switches, etc.): Tight or holding tanks are not present DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ,o 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.): Di gt•ri hiit-i nn hnx hac S r atara l No evidence of solids carry over-No evidence of leakage into or out of the box 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.): Pump c-hamhPr is not nr cent 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Kari Murray 681 Route Owner: West Barnstable,Mass. Date of Inspection: 1 1 f 1 1/o l SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan,excavation not required) 24 ' X7d ' T.aar•hi ng f i al rl 7d ' X?d ' If SAS not located explain why: Located see page 10 Type A leaching pits, number: leaching chambers, number:b leaching galleries,number: O leaching trenches,number, length: -0 leaching fields,number,dimension y �¢overflow cesspool, number: 6 v JJ innovative /' innovative/alternative system Type/name of technology: lle Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to clay to sand.No signs of hydraulic' failure- or ponding.Soils are dry.Vegetation is normal.The leaching field is in proper working order at the present time. CESSPOOLSL&Le- (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 0 Depth-top of liquid to inlet invert: ,yi9 Depth of solids layer: .fJA Depth of scum layer: A A Dimensions of cesspool: Materials of construction: 4199 Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Cesspool -, are not 1?scant PRIVYi!/�(locate on site plan) Materials of construction: ,IJiQ Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present. t 1 9 10/19/2001 14:25 5087753135 LEE BROWN, REALTOR PAGE 02 s yam, �j , TOWN OF BAMSTABLE LOCATION SEWAGE # VILLAGE_�j e)r �?l.Y ! ASSESSOR'S MAP& LOT r INSTALLER'S NAME&PHONE NO. a SEPTIC TANK CAPACITY Sa • LEACHIING FACILITY: ( PC) (size)NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet %te Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by •-ter-, Page 11 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:881 Route 6A West Barnstable,Mass. Owner: Kari Murra Date of Inspection: 1 1 1 3 01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water'0' 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 ground water elevation: Used; Gahrety & Miller Model.Ground water above sea level USGS; 92-0001 Plate #2 USGS; Observation well data- Top of Ground Leaching ` ;eet y GroundwaterN Feet Below Bottom of pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bottnm of the leachingit and the adjusted P ) groundwater table is gIN4 feet. 11 •nrnr,.-n.r..-.t,r-..,n-,...•..,.n..-�+n:..rr.+srn..+++.ni...+•.rn.n...•.�.u.+.-.r,vrwr, �_�_...<. ,-... TOWN OF Barnstable WARD OF HEALTH SUHHUFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••Tr1^T•'.'::.-r.lf.^.rrTIn1IT.-.1.•fRl 1•'Tlr 1lTtIlTTT'r-•.7r{rRTinIAI-'I'wTl.�rR�A/�ff.-.R7 nRnn v v, ..�rrr"'I�•�. -... -TYPE OR PRINT CI.EARL1'- PROPERTY INSPECTED STREET ADDRESS 881 Route 6A West Barnstable Mass. ASSESSORS MAP , BLOCK AND PARCEL # 156-028 OWNER' s NAME Kari Murray PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & San Inc COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Street Town or CJty State- ZIP COMPANY TELEPHONE (508 ) 775 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of ,inspection . The inspection was performed and any recommendations 1'egardillg upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: .� System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe environment as defined in 310 CMR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con lacted has found that the •system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature lefDate ecopy of this c tification must be provided to the OWNER, the BUYER On Where applicable ) and the BOARD OF HEALZ'll. * If the inspection FAILED, the owner or*""operator shall u within one year of the date of the inspection, unless allowed. ortrequiredm otherwise as provided in 3,10 CMR 15 . 306 . partd .doc T «�D ,v rz TOWN OF BARNSTABLE \/ I p/ el UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS vim" ASSESSORS MAP N0. PARCEL NO. ADDRESS 4.0� �ICi,A/ cSf. VILLAGE' L)1 64tw,5'/4�`ca CONTACT PERSON PHONE NUMBER O °� LOCATION OF TANKS: CAPACITY: TYPE OF FUEL. AGE: TYPE: LEAK OR CHEMICAL: DETECTION sYST�F,.M: DATE OF PURCHASE OF. EACH- 1. 2. 3. 4. 5. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. �,M �J / �� l U� �� f , �._____ ��- 6 � �� tj D n West.Barnstable Fire District............ 1201-75 ....._....-........_..........._.............._....." ivy PERMIT FOR STORAGE OF FUEL OIL In accordance with provisions of Chapter 148, G.L., and Regulations made under authority thereof, Name ELISE P. OWEN NELSON COAL & OIL _..................._...._............_._„...„._....„............._„„.„„.. _ .Name „„_.._..„....._...__.........._..._..._„„„..____...„....... Owner or Occupant Installer 881 MAIN ST, WEST BARNS. HYANNIS, MA. ¢' Address -- __.._...__....... ..._._....__..........Address ._„...._..._..._....„.._.. ,. Burner Storage Name OVAL STEEL ._„...„......._....._...__...._.....„_.....„.........„„...„„..„._.._.. Type of Tank „.„.._. ...... Manufacturer ..._._.. ........„..............._..—.._..._._.._...„„„.„_....Cap acity_...._275.. . „gals.(or) Size N/A Model No..or Size ___.._..---Location Location „ BACK YARD BY GARAGE rype....................._...._..... Mass. Approval No. Permit Issued 12.101.175,„ expires....INDEEINITE. H0J;N Dept. NO EEE N/A JOHN KINS CHIEF .I Fee_ .....O ..FEE.--.------ Paid By .. � I I BIOUSFIELD P.O. BOX 492 ASSESSORS MAP : FORESTDALE, MA 02644 PARCEL : TEST HOLE LOGS off ,j 508-888-2010 FLOOD ZONE : uT SO I L EVALUATOR : I� r I ,� � I q W I TNESS :"T) �� �- _OtI� I I� I �j�"1 � ��( 1 (�, �C�U,� 1 �� ` � '! (Cf REFERENCE : �`o* ��- U `1 � ( / DATE �?7 ��''k / 0��l PERCOLATION RAT!-':. .0 z M I _ 1 TH- I TH-2 f-++ I+f+ A o Loy s�'w L a G� �-- '� UAL LA��C: , cu2 I�.1 v 3 )5 � .}9N� 13 t) 1a L0CAT 10N MAP �� rs> � j5 2� -- TT i U ( f WLI(MP4 ,� 8 , _ ,20 --------- ,� -5_Z_ `/7 1 115 > SEPT I C; SYSTEM DES 1 C-N /50 '�'�)/,I t `f FLOW E`.T I MATE Y—BECROOMS AT //0 GAL/DAY/BEDROOM - GAL/DAY _7 � � ! SEPTIC TANK 1{ r ��1 J Fee, --ice, 1� � ---- d G,;L/DAY x 2 DAYS - CJQQ 9D GAL c� ELL { USE /f_.�GALLON SEPTIC TANKIt Iz i2b¢%'�� C �'l4DI►l� .r}-r 4 .� +' �tL (� SOIL A3SORPT I ON SYSTEM -- - '�-� i y �S ILD�I C� x py E� _ �' // ;: I DE AREA: /�/C3?— �9ti" / �`MOFMASsgcy ' BOTTOM AREA: ,.��' �c, r�( L�, = �q TERRY �'� rt� �'` I�AVANN #® / v4. 1 Nc�8721 -, 1066 SEPTIC SYSTEM SECTION 00 'IN 7 r p XL6j - pD / -AL t ! �� - --- �' 2A. / ,- SEP7. 1 C: TANK / SITE AND SEWAGE PLAN LOCATION : /sl7 \ PREPARED FOR : K42� ( 9 �3 ;uTt11r v SCALE : �7 T DAV I D B . MASON DATE : L�— ,� DBC ENVIRONMENTAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA �\ ; ( 508 ) 833- 2 11 77 I ASSESSORS MAP : 6A PARCEL : TEST HOLE LOGS - FLOOD ZONE : OT SOIL EVALUATOR : WITNESS _alb p {�. _ � _ ��� I r DJ, �-�i , REFERENCE : �L�►--I �____ � J ___ _ _. DATE .�..`' �JT1� /' ��� e llylobJig ) E* 130 _- PERCOLATION RATE :' ,--' z UA I 1 ` 7 Ufa TH- I TH-2 UT[L�I C ,_t �I�C-Q.I.��Z I�.1�j I 6 /L-724 LOCATION MAP X,, 251 - \ ; '12 1155 DEG-_/ 126 SEPTIC SYSTEM DESIGN _ LOW ESTIMATE f ✓/ l /� BEDROOMS AT �/D GAL/DAY/BEDROOM - GAL/DAY —�— � C�� 3 E P T I C TANK 't'1 GAL/DAY x 2 DAYS - 960 GAL � USE /� GALLON SEPTIC TANK L,��T�2b{='C7�� I SOIL ABSORPTION SYSTEM - SIDE AREA: � ` `r _— �Np AS BOTTOM AREA:. .� ?( Z� � � o���TERRY �FD � L — _ \ y ^' / S ANN 'WARNS , o / No.38721I -' a` _ SEPTIC SYSTEM SECTION t z , / CtL OG ------ ----- I . 00 9 Loki lj 71 AL � D-BOAC �,�'� °�`v%� =I��Z �0�� W�`��� �►a�l�;_ 1 ..-..' 5� / \ E P T 1 TANK h`` GAG/ I SITE AND SEWAGE PLAN 1 /50 PREPARED FOR : K4 2t / / vl� /'� ,3 h �J/ SCALE . DAV I D B . MASON DATE : DBC ENVIRONMENTAL DESIGNS D EAST SANDWICH . MA ATE HEALTH ( 508 ) 833- 2177 i — — T__ — — — — — ----—— ---- a