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HomeMy WebLinkAbout1000 MAIN ST./RTE 6A(W.BARN.) - Health 100.0 Main Street,West Barnstable. ~-SPEEDWELL BOAT`v ORKS, INC. 3 t I. S r f u No. 4210 1/3 BLU o � � ESSELTE 10% e o TOWN OF BARNSTABLE LOCA ON [000 I►?A/N Ir /i'��/� SEWAGE # VILLAGE �A�N ASSESSOR'S MAP & LOT p ©,Z // 'S NAME&PHONE NO. 19 SEPTIC TANK CAPACITY — � I SO C T o A.- LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER_ Ze)A Via / 1P? S 2: PERMIT DATE: CeNff 1+kNeE 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 GGr Il i� �oAr we,Plcs `i Commonwealth of Massachusetts /— 0� �v Title 5 Official Inspection Form y` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020. page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 6/0 on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. Rivers End Road Co � Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 06/11/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 f Commonwealth of Massachusetts �. ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This home has 4 bedrooms and there is a bathroom in the barn. The system consist of an H-10 1500 gallon septic tank for the house and an H-20 1000 gallon septic tank for the barn. They both tie into a D-Box that feeds 3-500 gallon leaching chambers. At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. !% 1000 Main Street Rt 6A V� Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts ,(!A Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............c u!% 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is West Barnstable MA 02668 06/10/2020 required for every' � page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I I Commonwealth of Massachusetts �n Title 5 Official Inspection Form k lie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form VV b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c� 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 plus GPD Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage well water 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Esta:)lishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of cccupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ?- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 36" house 19" barnfeet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20 plus feet feet Comments(on condition of joints, venting, evidence of leakage, etc.): Water was flushed and it came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 24" house 12" barn feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon house, 1000 gal barn Sludge depth: 5"/2" Distance from top of sludge to bottom of outlet tee or baffle 31"/34" Scum thickness 5"/ 1" Distance from top of scum to top of outlet tee or baffle 4"/5" Distance from bottom of scum to bottom of outlet tee or baffle 13"/ 12" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place in both tanks. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c � 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in wo:king order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(rote condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 i Commonwealth of Massachusetts p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form iia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of'Massachusetts `;ItIe �S �O:ffi'cial Inspection Form Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main'St LLC Owner Owner's Name information is West.Barnstable required for every MA 02668 06/10/2020 page. Clty/Town State Zip Code Date of Inspection D. System -information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ac. ' 11,PI in -' - 6 F t5insp:doc rev.726/2078 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy�"e_m-page 16 d 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 1000 Main Stree. Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 plus feet 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) ❑ A--cessed USGS database-explain: You must describe how you established the high ground water elevation: I auguered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 ( Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St LLC Owner Owner's Name information is required for every West Barnstable MA 02668 06/10/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION 1000 Main Street (6A) SEWAGE # VILLAGE �1( j,or lri,,e�SSESSOR'S MAP & LOT °�� ,Y/ INSTALLER'S NAME G PHONE NO. CASH ' S TRUCKING 362-3221 SEPTIC TANK CAPACITY H2O Holding Tank _., / LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Charles Birdsey DATE PERMIT ISSUED: ' , '" ' DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes NO `� __._.._._�---�. i i .. .�-�--r...�' �• ? � f � �' TOWN OF-BARNSTABLE LOCATION /AM R74- 7621 SEWAGE # 90 VILLAG ASSESSOR'S MAP LOT INSTALLER'S NAME PHONE NO. Gh'A�e� �7JZ SEPTIC TANK CAPACITY � � r LEACHING FACII.ITY:(type)T (size) NO. OF BEDROOMS PRIVATEDELOR PUBLIC WATER BUILDER OR OWNERlU�6"�/� DATE PERMIT ISSUED: �6 � C DATE COZIPLIANCE ISSUED: ` VARIANCE GRANTED: Yes No�►C -ea ego d , :v a' TOWN OF BARNSTABLE -LOCATION doo SEWAGE # t✓'" O VILLAG ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. JA-JC® SEPTIC TANK CAPACITY 9f l r :LEACHING FACILITY:(type) l (sue) l 2 NO. OF BEDROOMS PRIVAT �EbR PUBLIC WATER BUILDER OR WNER DATE PERMIT ISSUED: �� 9a DATE COZIPLIANCE ISSUED: VARIANCE GRANTED: Yes Na �o /0 1 r i 5EWA C4-E P-ERMIT U-O.2�T 1-I�l_ST_Q.l_-�.-E R-S-►J-L�,t�/-1-E-�-A.D DR-E S-S 6.0 I.L.D E R-5 - -& E- -A D D R-E- S l7 A-TEPE_R_M17-1 AT E�CO�/_l-P_L_I_L1.t�1 CE�i_SS_U_E17 : J ? 04�s\1 °Q . Fes$ _ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH / --------------OF..... . .......................... Appliration for 11ispniiFal Works Tonotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (&,-�an Individual Sewage Disposal System at: loo© r' � �............. .... .... ............................ � --------...._.-------------------- .......... ion-Add r ss •---------•----•--------------or Lot No. , ,�.--'— ----- .................. ........... Addreess s;--.---------------------------------------- �er d.-•----... `� j...-..���►f'ladl ---...------' --......-•-------------••----.....--•--•--- Installer Address UType of Building Size Lot____•................_.._._S. q. feet �. Dwelling-No. of Bedrooms........7.............................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Buildix�U)c"'i-M ' _..... No. of persons.......2-................ Showers ( ) — CafeteriaOther fixtures ----•---------------------•----•---------------- W Design Flow............................................gallons per person per day, Total daily flow............................................gallons. WSeptic Tank—Liquid capacity,&Co..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench;8'.*6 °.<Y—..._.,4 ..... Total Length.................... Total leaching area./ .2O0......sq. ft. Seepage Pit No.................... Diameter.................... Depth below inlet.................... Total leaching area......... ......sq. ft. Z Other Distribution box ( vY Dosing tank ( ) p(/2 ` fly'/3' S TCA'7 V Z/l S'`. - W Percolation Test Results Performed by.......................................................................... Date................................_....... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-._-_-.______-_.-_____-- GX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 • •• ...i:.........-•-• ..............•--------.......... .---- - ... r O Description of Soil.-bJ.�%_._5 �,2✓......t�-Q-1c-�..... x W __ UU Nature Re airs or Alterations—Answer when a licabl�. - P PP ----'-�----------------- ---- =-•---- Agreement: 27 The undersigned agrees to instal the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee b the b rn of health. Da Application Approved BY - --------7 1 O......................... .Dae Application Disapproved for the following reasons:................................................. ---------------------•-----------•----------•---••-•---------...-•-----•--•------•----.......-•-----•-••---•------------------------------------------•-••-- ........................................... -7 Date Permit No.---- ............_.. .. Issued...............-- ------------ Date _J No.... ;tl ...:. . '� FEs.. : :... ... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...---^�..........................OF.................................-.....:/ 1'`=='..............----------- App iration for Uiopoottf Works Tonotrurtion unti# Application is hereby made for a Permit to Construct ( ) or Repair (✓)" an Individual Sewage Disposal System at: ...............................................,.................................................. •••••••.....................••••••••-••••--••••--•........•------•••••......•••••............----- e Location-Address / or Lot No. 1 _ 1 — -- ---• - Owner Address w /1 Installer Address Type of Building Size Lot............................Sq. feet U Dwelling_-No. of Bedrooms............ :.............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building No. of ersons....._.2---------------- Showers a yP g '----=---------•----------•• P ( ) — Cafeteria ( ) QOther fixtures ...........................................I........................................................................................................... w Design Flow............................................gallons per person per.day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity�....:.....gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench--' Now:_.I..1=._._.__'Width!?......C.!..... Total Length.................... Total leaching area.................... ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.....__..__.._.___sq. ft. Z Other Distribution box (✓)" Dosing tank ( ) :" t _ i It � - 1 Percolation Test Results Performed by.................................... .................................. Date........................................ Test Pit No. I................minutes per inch Depth .of Test Pit.................... Depth to ground water--_-_-_--__-____-.__.--. �14 Test Pit No. 2................minutes per inch Depth of Test-Pit_-__-------:..... Depth to ground water........................ P4 ....................--...................................................................................................................................... O Description of Soil......................................................... ! � � .. /1 x U ----------------•-----...-----•.....------•---••••....--•-•••--.........--•--•----•--••......•-•----••...----------------•--------------•---------------------••--------•--•-•------••------------------ w UNature of Repairs or Alterations—Answer when applicable................................................................................................ -- --•-••----------------------•-----------------..._---••--••--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed---'.......:............................................................................ �. ................................ Date Application Approved By---=................................................ -` ----:.::_'........................ -•------�� Date Date Application Disapproved for the following reasons---------------------•------•----------------------------------•--------------------------------------•-----•---- ----•---•-•-••-------••----•-----••---------•---••-•.................•----------..........--•-•••-----------•----•-----•------------...-----------•----------------•----------------------•-----•-•-•-•- ` Date Permit No.................i Issued....-----•.7.1/Z------ � =,...Date....--- .....---•--•--------••--•--•---^ ( Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......`.......................OF....................................................-....:............................. Trr#ifiratr of Tomptiatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (k ) by _`----------•-....•..................•••••..........------. ----•-•-•-••-•-•......_..----•----••-------•-••-•-•-...---------••......---•-••....._........-- Installer at........................................................................................................................................ has been installed in accordance with the provisions of T7"7Z 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------- --=----- dated.--.._._.-�1j._.....__l_.__-.'.....__..._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... _!_. ..". .... Inspector ....... THE COMMONWEALTH OF MASSACHUSETTS - J BOARD OF HEALTH 1 ....................OF............. No......................... FEE...........::.�....:. Diopooa1 Works �onotr ion amit Permissionis hereby granted............................................................................................................................................... to Construct ( ) or Repair K) an Individual Sewage Disposal System at No.......•..........I r- 1 r I = ; I 1 --------•-•••........................•---•---..... .......--••••--•---.....---------.....-•--------------------------•-----------------------------••----•....... Street _ // as shown on the application for Disposal Works Construction Permit No................`..: Dated....__jI._:_.:' r ..............................................•---..._-'`.._-____..,--•---•---------•----...-----•-••-- / Board of Health DATE........ = •---------.--------- ....................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 2 �-L�� ��� ��� �� i �� � � ��. ��� _�,�__ r••R d No...Cf Fl*s.....8-6?....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrnrtinn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1000 Main Street (6A) ................__. ._.......... - Y ................................... ... .... Location-Address or Lot No. .......... -Charles Birds ............... .... Owner Address W CASH ' S TRUCKING Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms.............................. ._...Ex Expansion Attic a g— _.____.__ p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------•------------------------------------------------------------------------•-----------------•----------.......---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity.........._.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by..........................................................................'Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4A Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ a ----------------=----------------------------------•---.._..----------------........._...._.................................................................. 0 Description of Soil................------------------------------------•---•----•--•-----•---••-- --------------------------------------------------------------.............._........--- x U = W x --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----.....-- U Nature of Repairs or Alterations—Answer when applicable .n st a 11 i_n g 2 0--_h o 1 d i n-g-.-tan]cQ n 1 y ---------------------------------•----------•---------------------------------......•--.----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant has been issued by the board of health. 9/28/94 Signed ......... .. ....._..X�--' ............-........................ Ens;ign Cash d/b/a CASH ' S TRUCgII4be Date Application Approved By ................ Application Disapproved for the following reasons- -------------------------------------------------------------------- -- ----------------- ----------- ------------...... ----------------------------------- ------------------------------------------ ------- ----------------- -------------------- -- -------------------------------------------- -- - --------- .................................... 'J -7 Date PermitNo- ........ ----=�/--- �-..l.../----------------...---- Issued .--- ........................................................... Date i =� ► 7 G° Ficz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrnrtiun 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1000 Ma.-.in.. Street(6A) ......... _...... ............Location-.Address . :....... or Lot No. - ._............... .... ...........Char 1 e s B a.r d s.e v-----•--------...-•----•-------•-- --....--•-----------•-•----•--------........._.........- ......................... _ ......................... Owner Address W CASH' S TRUCKING.... ......_..... 1.4 M Installer Address UType of Building Size Lot............................Sq. feet 1—I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 e of Building a Other—T yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures = ...-----•------ W Design Flow....................:.......................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet......_............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing-tank ( ) Percolation Test Results Performed by.......................................................................... Date....................- W ----------------- Test Pit No. I................minutes per inch Depth of,Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit---:................ Depth to ground water-----.................. .--•--••-----------------••--•-••----•-•----•-•----------------.....--•---......---- O xDescription of Soil-•--------------------•------•-•----........--------•---.....----------•--••------------------------------------------------•-----------------•-•-•••-----...-----.--•-- W x -•----•-•--------------------------•••-----------•----•-------••------------•--•------•------------------•-•---------•---•...---------•---•--------•----- --- U Nature of Repairs or Alterations—Answer when applicable.-___ .n t a 11 in a-__ .... a n k#n n l y ..........•---------------------••--------------•----------------------••-----------.....-----......----••------------------------------------••-------•---------------------------•••••-------•----••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ---------.�............`---- ----------- �------ ...9./28./94 ------ A Application Approved B Erf�j�C' .h% ASH ' S TRU I Date PPPP y -------------- v -�..<,.,^-,�.................---- --............-------------------- -----------------... . ........ ' -_�s __/.j- Date Application Disapproved for the following reasons- ------ ------ ------------------------------------------------------- - -------------------------------------------------- --- - -------------- -------- --- ----------------------- -- ---------- --------------------- --------------------------- -------------------------------------- ..................................... Permit No. ......... ---- 7 Date .................................................. Issued -----------------------................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�Ez#tftca#e of Taraylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( - ) or Repaired ( ) by--- CASH' S TRUCKING P.O. BOX 7 Yarmou.thDo.rt-,.Q2,05_______________________ _____.................____ Installer at --- _00Q...stain...-Street-(-6-A.)....1�..<.....>3 .r.nG ah�. ....0.?..ti.ti (. Fm - --------- has been installed in accordance with the provisions of TITLE 5 cof The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...... -.-.SP ............. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ED:7AS A GUARANTEE THAT THE SYSTEM WItUFUNCTI� ,,1 SATISFACTORY: DATE ------------ ---------................................................. -------- Inspector .........................--------------------•---- ------ --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �'�_�:,1 TOWN OF BARNSTABLE No.- FE ... ....... Disposal Vorks Tnn#rnrtion rrnti# Permission is hereby grantedCASH ' S TRUCKING P.O. BOX...7._.Xaarmouthr ort.,.-.•Q?675 .. . ... . --.---. -- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No.......1000 Main Street (6A0 W— Barnstable---026C£3---(.ownpr.)....rbar-1_e�__.� •r����� -............. ---------------------------------•------ •- Street 99 v as shown on the application for Disposal Works Construction Permit !-'t..--.... .... Dated........ ..�y r ........................................... �-•---- yBa DATE rd of Health ....................... ./._ _ FORM 3880E HOBBS 6 WARREN.INC.,PUBLISHERS A. No.._r-�..................... . ..� THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALT _. ...��, h.......OF.............. . .... ....- :... -- Appliratinn -for Diapviial Vork,6 Totuitrurtion Pprinit Application is hereby made for a Permit to Construct ( ) or. Repair ( ) an Individual Sewage Disposal System,at: 1 - p` ---------- ................ -------------------- . ..................................•Address �LotN.. Address ner ....................•--•--...... Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms____________________________________ _______Expansion Attic ( ) Garbage Grinder ( ) Q' of Building_. ----_ ....of persons.. ______________ Showers ( — Cafeteria fixtures tf ) ) Other—Type - ----1 ,, -- ---- ------------------------------------------------------------ Other W Design Flow............................................gallons per pe yoi<s n�day. Total daily flow--------------------------------------------gallons. WSeptic Tank l Liquid capacityA gallons Length---------------- Width--------------- Diameter---- Depth- ------------ x Disposal Trench—No.-------------------- Width__?Q........... Total Length...2;�o........ Total leaching area_._1U -----sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below i`et___ .Total leaching area--._.._..--____sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------------- ------------------------------------------------------------ Date--------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit_..,___.--__--____.- Depth to ground water..-.---...___-._-._...-- f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.---.-______--____... O f-.._...... �-----sue---/--• -•-------------- 14................(........r Description pf Soil - ------�-- � ` l�`-'d....... ----------- -- - U ............ 74 XV V Nature of P.epatrs o�Alterattons—`ttfnswer when applicable. ---------------------------- ----- Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the>md of health. igned. .!. -- - --------`----------------------------------------------------- ' ate Application Approved By...... L Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------- •---•---•----•-•---------------------------------•----------............................................................. --------------------------------------------------------------------- 4yDate PermitNo---------------------................................... Issued.... ---- _-�------, ---•--•---- Date D THE COMMONWEALTNI.OF MASSACHUSETTS BOARD O .—=ALT 1,=- . ... _O F....... . .... Appliratiuo -for Uiipoott1 Works om6urtioo Permit Application is hereby made for a Permit to Construct ( ) or. Repair ) an Individual Sewage.Disposal System at: oc tion•Ad T. or Lot No. . .... w Owner h• Address p nstaller Address Type of Building Size Lot............................Sq. feet -, Dwelling—No. of Bedrooms------------------------------------ -------Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Buildin .,6A_le„._- of persons.- - -_- -__ -- Showers ( ) — Cafeteria ( ) Other fixtures -_!""' -r 1 6�'�'�'� �------.......................................'---------.......•----- w Design Flow..,.. -- "-"."~= •....gallons per pe otlg n per day. Tota dI aily flow............................................gallons. WSeptic Tank-jLiqulkl capacity-&40-gallons Length---------------- Width----- .....-. Diameter-----..--------- Depth-:-_-.--... x Disposal Trench—No..................... Width---2Cj.-......... Total Length----�C�........ Total leaching area....1G___.___----sq. ft.• Seepage Pit No----------- ---- Diameter.............._---- Depth below i et....._.._...._._.__ Total leaching are a------------------sq. ft. Z Other Distribution box '(, 1 Dosing tank ( ) C • aPercolation Test Results 'c ,,; ..;erformed by:.....: ................................................................. Date-------..------------------------------ a est Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water._..._-_----.-----_- L14 Test Pit No. 2----------------minutes p inch Depth of Test Pit.................... Depth to ground water.....----_--_-----.--_- ft -- ----•-••--•--• ••--- -•-- Descrt tio�fi �,t y�„r . --.. -•----------------------------------------------------- - -------------------- p Its k ,� cx, --- --•-•--- --•----••---•---•-------•--•---•------•-•--•---•----------------•------------•-----•------••--••...:------------------------------ w - --------- UNature of Repairs or Alterations—Answer when applicable-----------------------=------------------------------------------------------------------------- ------ ----------- ..-------------------------:--------------------------------.....--------------------------------- Agreement: The undersigned agre&s­to install the aforedescribed Individual.Sewage Disposal System in accordance with the provisio `of;,rticle XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation un l to Certificate:cf-Compli ce has been issued by he bo of health. :•,, ne ......... Aif,?*------------ ApplicationApprbved BY------------------------- ----••-•-•---------•------•--------•-----•----- ...................... Date Application Disapproved for the following reasons:....................................................................................-------••--•--•------------ ................................................= --------- ............................ ---------------------••---------•-•---•-•-•--- -•-•---- -- --- ..................... .:.., .z Date 6 Permit No-------------------•..... --•----....................... Issued-- �. Date ---------------•---- i.. i THE COMMONWEALTH OF,MASSACHUSETTS . ��•,, � �! .- BOARD F HEAL f{ • ti. 0441 ..:�...................OF....................... • �...................................................... �prtifiratr of f�rrnii�tnre �' ,•T G TIC. Individual Sewage Disposa ys in co structed ( ) 'or Re red ( ) L , � at........... ` ------- --------- - ---- -------- ----------•--•---•-•----------------------. --------- - - has been installed in accordarf&-,'with the provisions of Article NkVO*State Sanitary 01 cr' h' •in the application•for Disposal Works„Construction Permit No----:........................... dated----------------................................ `. ' THE ISSUANCE;O.F.,THIS CERTIFICATE SHALL. NOT BE CONSTRUED-AS A GUARANTEE THAT THE SYSTEM WIL FUNCTION SATtSFAC.TORY. DATE Inspector ------------------- AV. .l -------------------- vr. THE COMMONWEALTH OF MASSACHUSETTS BOARD A T H ' ?;.O F........r No.:.::....-•............. , FEE........................ 'Bin � �umitrurtion �r mit ' Pe�issihee �..grante d__________________ ___ ...r.__ _.....0) .to C i 'Ixe Indi�}f Sew-a e !/Y' at No. - f� --•••-•---•--- �{ rC as shown on the a plieati for"Disposal Works Constructio�tet _- ated.......................................... AA l•�*z D -,� �' •--------------------------- -------•-------t �------.. --..._ Board of Healt DATE-- . ---------- --....................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No. �7 � ' Fee (JO BOARD OF HEALTH TOWN OF BARNSTABLE 01pplication _for Yell ongtruction Permit Application is hereby made for a permit to Construct Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel /46� �. ato ��+. (�. $ctvrls� � a \1 Owner Address c-: m yN TACtVV Installer-Driller - Address Type of Building / Dwelling Other-Type of Building No. of Persons Type of Well -PVc�- Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described 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 Co plan as en issued by the Board of Health. Signed / S07 1 /3 6 IS ate Application Approved By 13 /Zo/ Date Application Disapprove Zore following reasons: � ��f Date /N Permit No.I ("V 17 ` 0 2 Issued -5 Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of tom Yiance THIS IS TO CERTIFY,that the individual well Constructed Altered( ), or Repaired( ) l \ l Installer at Mal n �a�h(Sta,��p 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 FUNCTION SATISFACTORILY. Date Inspector No. (ICJ C'� � o Fee 00 BOARD OF HEALTH TOWN OF BARNSTABLE 0[ppYication jFor Yell ougtructiou Permit Application is hereby made for a�permit to Construct , Alter( ), or Repair( ) an individual well at: —100 jil ]Rgji, n:5� Wt2 1:7 C44 n2 Locatio�d ress Assessors Map and Parcel caner Address Installer-Driller) Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described 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 Complian has ,e6n issued by the Board of Health. Signed Efate Application Approved By I Dae Application Disapprove, e following reasons: Date ` Permit No. J y 1)J7 Issued 5- Date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of �omc Yiauce THIS IS TO CERTIFY,that the individual well Constructed Altered( ), or Repaired( ) by Ai 1.�1 Installer at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. .Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Very Cougtructiou Permit a) No.W Cam/1 r 1 Z Fee Permission is hereby granted to 1T1��'�. , 614 1 �stalljr,, to Construct(vr,-***'Alter( ), or Repair( an individual well at: Street as shown on the application for a Well Construction Permit No. n,.�Zo I r,— 0 1?Dated 5 J 7 /mc Date Approved By _ i a-- Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -�-, m 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is West Barnstable ✓ Ma. 02668 01/26/2017 required for every R7 page. City/Town State Zip Code Date of Inspection q .C• Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections 4:1 Company Name 624 Old Barnstable Road AA Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 01/28/2017 In ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•PageN1.of 177 I/c kv�jfC�C., V J Commonwealth of Massachusetts v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This home has 4 bedrooms and there is a bathroom in the barn.The system consist of a 1500 gallon H-10 septic tank for the house and a H-20 1000 gallon septic tank for the barn. They both tie into a D- box that feeds ( 3 ) 500 gallon leaching chambers.At the time of the inspection there was appx. 6 inches of ponding water and there were no visable signs of past hydraulic failure.The s.a.s. has four plus feet of seperation from ground water. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M •'' 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 7 Y Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "y es" to an question in Se ction on E the system is considered a significant threat,Y Y Y q Y g eat, 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•,3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 l � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® C1 Was the facility or dwelling inspected for signs of sewage back up? ® I] Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Well water 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36" house 19" barn feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 24" house 12" Barn feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon house 1000 barn Sludge depth: 3" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is West Barnstable Ma. 02668 01/26/2017 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 35" Distance from bottom of scum to bottom of outlet tee or baffle 5" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local septic pumping Co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection 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 °M 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Three ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there was appx. 6 inches of ponding water and there were no visable ins of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately h � 1� ,Mouse s G Dlr,�Ve- w c,l q, C IS /� Cr v > ` s o� �p z ;° 101, A% NO t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f TOWN OF BARNSTABLE LOCATION. 000. MA/.✓ JT ?1 -0 SEWAGE M VILLAGE L ARA" ASSESSOR'S MAP&:LOT S NAME&.PHONE NO. SEPTIC TANK CAPACITY SE A71 G /tise-Z"c Ti o/t. LEACHING FACILr1'Y:(type) .(size) NO.OF BEDROOMS BUILDER OR OWNER �AV is 13/i?b S£Y PERMITDATE: C 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 2W feet of leaching facility) Fat Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 66r i 11 ooAr Aovrks i - �s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is West Barnstable Ma. 02668, 01/26/2017 required for every page. Cityrrown 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: 11 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole to 11 feet to show four plus feet of seperation from ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M0 1000 Main Street Rt 6A Property Address 1000 Main St. LLC Owner Owner's Name information is required for every West Barnstable Ma. 02668 01/26/201.7 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 6 ro,. z, E�OTTD r- y f: G er—cLr 0 n y p J f Feet! v I A)-3 H Z0 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I f NOTES TO THE FILE October 21, 2008 Speedwell Boat Works. 1000 Main St. West Barnstable Cynthia Martin, BOH This business filed a Toxic and Hazardous Materials On-Site Inventory on an unspecified date. An inspection of the facility on October 21, 2008 revealed that Speedwell Boat Works is no longer in business. Mr. Charles Birdsey, who was on site,reported that he no longer works on boat building. The barn, garage and two sheds contained no hazardous material other than what Mr. Birdsey and his son use for their personnel use. Two boats owned by the Birdseys were stored in the barn.. There were several small boats being stored outdoors on the property but there was no evidence of any maintenance being performed. TOXIC AND HAZARDOUS MATERIALS hl(GISTRATION FORM NAME OF BUSINESS: 9pee&L,3< A . Mail To: BUSINESS LOCATION: t oo o W . (�o,2�5-��.6 le, rn Kf Board of Health Town of Barnstable MAILING ADDRESS: a03 S . Or�1����`ad . 0rz\fa_1Q%- n,i+ P.O. Box am 534 TELEPHONE NUMBER: ( 5,01) ay o - 2)100 (�so 6�3�a- g s�b Hyannis, MA 02601 CONTACT PERSON: Cko,ake s Y,�i',zAse• EMERGENCY CONTACT TELEPHONE NUMBER: ag0 -- -a9 0 0 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO,_ This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid (including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes _ _ (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy- Health Department/ Canary Copy-Business