HomeMy WebLinkAbout0881 MAIN ST./RTE 6A(W.BARN.) - Health 881 MAIN ST. ,W.BARNSTABLE
A = 156 028
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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
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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
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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
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