HomeMy WebLinkAbout1022 MAIN ST./RTE 6A(W.BARN.) - Health 1022 Main Street
W. Barnstable
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A TOWN OF BAk&STABLE
LOC,ATION 10a rL J- rZ G SEWAGE # _._.
VIL-Vn GE W-e S �'►' ski ASSESSOR'S MAP & LOT/� '
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I S Gt 0(ki �jr a 3
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER V
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
o -
1
Town of Barnstable
NP o� Regulatory Services
+ BAxivsrABLE, Thomas F. Geiler,Director
9� MASS. .•� Public Health Division
ATEp��a
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax. 508-790-6304
January 16 2007
Mr &Mrs Richard C. Vigeant
1022 Rte 6A
West Barnstable, MA 02672
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5
The septic system owned by you located 1022 Rte 6A,West Barnstable, MA was last
inspected December 41h 2006 by Patrick T Sullivan, a certified septic inspector for the
State of Massachusetts.
As the result of the subsequent review by the Town of Barnstable Plumbing Inspection, it
was determined that you inspection dated December 4th 2006 should be changed to
PASSED under the guidelines of 1995 TITLE 5 (310 CMR 15.00).
If there are any questions about this reminder, please feel free to contact the Barnstable
Health Department.
BARNSTABLE HE TH DEPARTMENT
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
i
COMPLETE THIS SECTION ON DELIVERY
SENDER: COMPLETE THIS SECTION
■ Complete items 1,2,and 3.Also complete A. Sign ure
item 4 if Restricted Delivery is desired. Agent
'(
N ■ Print your name and address on the reverse X 4 Y/ 2 ❑Address
so that we can return the card to you. B. Rece ed by(Printed�/Qr
me) C. Date of Deliver
■ Attach this card to the back of the mailpiece, — ,� T
or on the front if space permits.
11
D. Is delivery address different from item 1? ❑y i
1. Article Addressed to: If YES,enter delivery address below: GrNo
1VIr &,Mrs Richard C. Vigeant
1022 Rt6A
3. Service Type
West,Barnstable,.MA 02672 ❑Certified Mail ❑ Express Mail
❑Registered ❑Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes Tit
jt
2. Article Number 7 O S' 116 0 0000 01�91 2823
` (transfer from service label)
!� PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STATE / s
fA- . 4 A 12 M ,K � FFU_ ass"'
• Sender: Please print your name, address, and ZIP+4 in this box •
PUBLIC HEALTH DIVISION
TOWN OF BARNSTABLE
200 MAIN STREET
hYANNIS, mASSACHUSSETS 02601
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(Endorsement Required) Jf Here O
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Certified Mail Provides: as�ana r'008£uuad Sd
o A mailing receipt ( H)z00z aun
o A unique identifier for your mailpiece
o A record of delivery kept by the Postal Service for two years
Important Reminders:
o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
o Certified Mail is notavailable for any class of international mail.
o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
o For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
o For an additional fee,,delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery":
o If'e postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
Internet access to delivery information is not available on mail
addressed to APOs and Ms.
I ,
Town of Barnstable
GF tHE Tp�
do Regulatory Services
.�
BARNSTABLE ; Thomas F. Geiler, Director
9� MASS •�� Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
January 10 2007
Mr&Mrs Richard C. Vigeant
1022 Rte 6A U' f
West Barnstable,MA 02672
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5
The septic system owned by you located 1022 Rte 6A,West Barnstable,MA, was last
inspected December 41h 2006 by Patrick T. Sullivan, a certified septic inspector for the
State of Massachusetts.
The inspection of your septic system showed that your system"Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Sewer line exits the house 42" above the present water supply line. a al
setback is ten (10) feet per the State Environment Code.
You have 2 years to relocate the sewer line or the water line o you hve opti n of
sleeving the sewer line.
If there are any questions about this reminder,please feel free to co e Barnstable
Health Department.
BARNSTABLE HEAL H PARTMENT
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
of the►°�
_ o Regulatory Services
anx�v�ns Thomas F. Geiler, Director
9� 16 9. •• Public Health Division
iDrEn�+"
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
January 10 2007
Mr&Mrs Richard C. Vigeant
1022 Rte 6A
West Barnstable, MA 02672
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5
The septic system owned by you located 1022 Rte 6A,West Barnstable, MA was last
inspected December 4th 2006 by Patrick T. Sullivan, a certified septic inspector for the
State of Massachusetts. ` o
The inspection of your septic system showed that your system 44eifs"under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Sewer line t.
Aom"'. C'X,47-6�e �vao.-- pry /—&- Av-
You have 2 years p iance. S�?�d
` -1--0 rr v s+.ucr "4 or- � �
If there are any questions about this reminder, please feel free to contact the Barnstable
Health Department.
BARNSTABLE HEALTH DEPARTMENT -4,-3a-A ZIPS'" off_
Thomas A.McKean, R.S., C.H.O.
lae
Agent of the Board of Health
_t
COMMONWEALTH OF MASSACHUSETTS
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 0� og4
CERTIFICATION
Property Address: 1022 Route 6A,West Bastable,MA 7�
Owner's Name: Richard C.Vigeant and Lynn E.Vigeant
Owner's Address: 1022 Rte.6A,West Barnstable,ME
Date of Inspection: 12/04/2006
Name of Inspector.Reid C.Ellis
Company Name:Ellis Brothers Const.Co.
Mailing Address:23 Enterprise Road
Yarmouth Port,MA 02675
Telephone Number:508-362-6237
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and;complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper fimction and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15—W of Title 5(310 CMR 15.000). The system:
�. — Vie. ,tR , �• �f ii L(a q
nbona�y
aluation by the Local Approving Authority
Fails
Inspector's Signature: Date-./
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments i� / lvU A&t& I CU
Iola)
****This****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.
1.
Title 5.Inspection Form 6/15/2000 page I
C •
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1022 Rte 6A,West Barnstable,MA
Owner: Richard C.Vigeant and Lynne E.Vigeant
Date of Inspection:12/04/2006
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 Zany of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist Any failure criteria n t evaluated are indicated below.
Comments:
B. System Conditionally Passes: oetll
One or more system components as described in a"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacem or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the or 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 oi tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as ipproved by the Board of Health.
"A metal septic tank will pass inspection if it is structure ly sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is availat le.
ND explain:
Observation of sewage backup or break out or hi static water level in the distribution lox due to broken or
obstructed pipe(s)or due to a broken,settled or uneven button box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are placed
obstruction is 70 ed
distribution box is 1 veled 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 re placed
obstruction is remov d
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1022 Rte.6A,West Barnstable,MA
Owner: Richard C.Vigeant and Lynn E.Vigeant
Date of Inspection: 12/04/2006
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
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 coliform
bacteria and volatile organic compounds indicates that the well is fee 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. Other:
3
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1022 Rte.6A,West Barnstable,MA
Owner: Richard C.Vigeant and Lynne E.Vigeant
Date of Inspection:12/0412006
D. System Failure Criteria applicable to all systems:
You must. dicate"yes"or"no"to each of the following for all inspections:
Yes N
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
J16scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_/R$4un-ed
'c liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
pool
d depth in cesspool is less than 6"below invert or available volume is less than day flow
_ pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
f pumpumpedP
y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
IWO supply.
J^3 portion of a cesspool or privy is within a Zone 1 of a public well.
_ y 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)Th [Ia4s.I have&mined 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 e a facility with a design now of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the Mowing:
(The following criteria apply to large systems in adcfi ion to the criteria above)
yes no
the system is within 400 feet of a surface water supply
— _ the system is within 200 feet of a tributary i o a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone H of a public water supply well
If you have answered"yes"to any question in Sectioft E the system is considered a significant threat,or answered
`y � Y
es"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
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1022 Rte.6A,West Barnstable,MA
Owner:Richard C.Vigeant and Lynn E. Bigeant
Date of Inspection: 12/04/2006
Check if the following have been done.You must indicate es"or"no"as to each of the following:
Y 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,4tcluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
Of th affles 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:
Ye `
Existing information.For example,a plan at the Board of Health. A
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unac_ceptable)[310 CMR 15.302(3)(b)]
5
i
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM
INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1022 Rte.6A,West Barnstable,MA
Owner: Richard C.Vigeaut and Lynn E.Vigeant
Date of Inspection: 12/04/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ..: Number of bedrooms(actual):
DESIGN flow based on 310 CMj,15.203(for example: 110 gpd x#of bedrooms): 5
Number of current residents:Does residence residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no);jeV[if yes separate inspection required]
Laundry system inspected(yes r no),.&�
Seasonal use:(yes or no)-
Water meter readings,if avail(last 2 years usage(gpd)):
Sump pump(yes or no): !�
Last date of occupancy: `
COMMRCIAL/MUSTRIAL
Type of establishment: ;"-5 6
Design flow(based on 310 CMR 15.2 ):
Basis of design flow(seats/persons/sgft,etc.): Q '1
Grease trap present(yes or no):-447
Industrial waste holding tank present(yes or no):A
Non-sanitary waste discharged to the Title 5 .systM yes or no):104V
Water meter readings,if available:
Last date of occupancy/use: gq;& I/
OTHER(describe):
GENERAL INFORMATION
Pumping Records r ,� ,,�
Source of information-�1of
-
Was system pumped as part o e 'o (yes or no):
If yes,volume pumped: ions—How yvas quantity pumped determined?
Reason for pumping:
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)
Tight tank _Attach a copy of the DEP approval
—Other(describe):
Approximate age o co ents,d t msx�lled(if )and source of inf tion: 7
rat/ -C_— 15
O r 1; �/�' es or no -
l?
Were sewage odors wen amvmg at the site(y )
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1022 Rte.6A,West Barnstable.MA
Owner: Richard C.Vigeant and Lynn E.Vigeant
Date of Inspection: 12/04/2006
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private watersupply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:—(locate on site plan)
i
Depth below grade:
Material of construction: concrete metal fi _berglass polyethylene
other(explain) — — —
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or bale:
Distance from bottom of scum to bottom of outlet tee or bale:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: (locate on site plan)
Depth below grade:—
Material of construction: concrete_metal fiberglass_polyethylene—other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping.
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1022 Rte.6A,West Barnstable,MA
Owner:Richard C.Vigeant and Lynne E.Vigeant,
Date of Inspection: 12/04/2006
TIGHT or HOLDING TANK: (tank must be p time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal �
rglass olyethy other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: J%present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:AW
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage iaW or out e :e fl
PUMP CHAMBER: (locate on si7","",Ax
.
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,conditioi t of pumps and appurtenances,etc•):
8
� R
I
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1022 Rte 6A,West Barnstable,MA
Owner:Richard C.Vigeant and Lynn E.Vigeant
Date of inspection: 12/0412006
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
i
Type 1�
leaching pits,number.
leaching chambers,number
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number.
innovative/alWmative system Typeiname of technology:
Comments note condition of soil,signs of hydraulic failure,lev ponding,damp soil,condition of vegetation,
etc.): ® r
CESSPOOLS: cesspool must be pumped as part of spectton)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer. i
Depth of scum layer: i
Dimensions of cesspool•
Materials of construction.
Indication of groundwater inflow(yes or no): j
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i
' E
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.):
9
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1022 Rte 6A,West Barnstable,MA A ,
Owner: Richard C.Vigeant and Lynn E.Vigeant `V
Date of Inspection: 12/0V2006
S�CETCH OF SEWAGE DISPOSAL SYSTEM
Ptbvide a sketch 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.
lI
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o gsjb r 0
1,
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1022 Rte,West Barnstable,MA
Owner: Richard C.Vigeant and Lynne E.Vigeant
Date of Inspection:12/04/2006 ry,
SITE EXAM
Slope 1�/ c�4G GS /!-s �!�� dtli� �.1e
` _
i ��,�V
Check cellar �� d
Shallow wells L? �
I
Estimated depth'to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-
Accessed USGS database-explain:
I
You must describe how you established the high ground water elevation:
00
a a • 4" 6.4
+ 45?/ 1401,44i�
11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
't 1022 Main Street(Route 6A) West Barnstable ✓ M- 178 P-22
Property Address -
Richard Hawkins ,
Owner Owner's Name 1 �k
information is
required for every 110 Sultan Point Road, Barnstable MA 02630 October 14, 2015
.�.
page. Cityrrown State Zip Code Date of Inspection 1:
Inspection results must be submitted on this form. Inspection forms may not be altered in any GQ
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 Troy Williams
use the return Name of Inspector
key.
Troy Williams Septic Inspections
Company Name
19 Hummel Drive
Company Address
South Dennis MA 02660
City/Town State Zip Code
(508) 385- 1300 S1682
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
S October 14, 2015
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
10f,6ped rs
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurfa
ce Sewage Disposal System Form Not for Voluntary Assessments
M .•°r 1022 Main Street(Route 6A), West Barnstable
M 178 P 22
Property Address
Richard Hawkins
Owner
Ow ner's Name
Information is
required for every 110 Sultan Point Road, Barnstable MA 02630 October 14, 2015
page. Cm State Zip Code Date of Inspection
B. Ce
rtification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: .
®
I have not found any I'nformation 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:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
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•3113 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
1022 Main Street(Route 6A),West Barnstable M- 178 P-22
Property Address
Richard Hawkins
Owner Owners Name
information is required for every 110 Sultan Point Road, Barnstable MA 02630 October 14, 2015
page. Cityrrown 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/alar.ns 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
s ,
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.•°'t 1022 Main Street(Route 6A), West Barnstable M 178 P 22
Property Address
Richard Hawkins
Owner Owner's Name
information is 110 Sultan Point Road Barnstable MA 02630 October 14, 2015
required for every ,
page. Clty/rown 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 %day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1022 Main Street(Route 6A),West Barnstable M- 178 P-22
Property Address
Richard Hawkins
Owner Owner's Name
information is required for every 110 Sultan Point Road, Barnstable MA 02630 October 14, 2015
page. Cityfrown 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 16.303, 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 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1022 Main Street(Route 6A),West Barnstable M- 178 P-22
Property Address
Richard Hawkins
Owner Owner's Name
information is required for every 110 Sultan Point Road Barnstable MA 02630 October 14, 2015
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)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3+ retail Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3/13 Title 5 Official Insp
ection 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
1022 Main Street(Route 6A),West Barnstable M- 178 P-22
Property Address
Richard Hawkins
Owner Owner's Name
required fo is 110 Sultan Point Road Barnstable MA 02630 October 14 2015
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Total design is 440 gpd. 330 gpd for bedrooms plus 110 gpd for shop/retail/office space.
Number of current residents: 2
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 years usage d Private well
Detail:
Well is 122'from leaching.
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: shop/retail/office
Design flow(based on 310 CMR 15.203): 110 gpdGallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): 75 gpd per 1000 sgft
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: private well
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1022 Main Street(Route 6A), West Barnstable M 178 P 22
Property Address
Richard Hawkins
Owner Owner's Name
information is required for every 110 Sultan Point Road, Barnstable MA 02630 October 14, 2015
page. Cltyfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: occupied
Date
Other(describe below):
N/A
General Information
Pumping Records:
Source of information: No pumping info available.
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•3/13 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
1022 Main Street(Route 6A),West Barnstable M - 178 P-22
Property Address
Richard Hawkins
Owner Owner's Name
information is 110 Sultan Point Road Barnstable MA 02630 October 14 2015
required for every >
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
D-box and leaching were installed to existing tank on 9/22/93 per compliance.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1811+
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.):
Lines were found clear at the time of inspection.
Septic Tank(locate on site plan):
Depth below grade: 1
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: 5'X9'X6' 1000 gallon
Sludge depth:
4"
t5ins-3113 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
•° 1022 Main Street(Route 6A), West Barnstable M- 178 P 22
Property Address
Richard Hawkins
Owner Owner's Name
information is required for every 110 Sultan Point Road, Barnstable MA 02630 October 14, 2015
page. City/Town 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
21811
Scum thickness none
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? probe/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.):
Inlet and outlet tees were found present and in working order. No evidence of leakage or damage
was found. Tank was not in need of pumping at this time.
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
t5ins•3113 Title 5 Official Inspection Forth: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
1022 Main Street(Route 6A),West Barnstable M - 178 P-22
Property Address
Richard Hawkins
Owner Owner's Name
information is required for every 110 Sultan Point Road Barnstable MA 02630 October 14, 2015
page. Cityrrown 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: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: N/A
Capacity: N/A
p . �' gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments(condition of alarm and float switches, etc.):
N/A
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1022 Main Street(Route 6A), West Barnstable
M - 178 P 22
Property Address
Richard Hawkins
Owner Owner's Name
information is 110 Sultan Point Road Barnstable MA 02630 October 14, 2015
required for every ,
page. Cityfrown 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 level
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was found level and in working order with equal distribution to outlet lines. No evidence of solid
4 carry-over or backup in the past was found at the time of inspection
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.):
N/A
*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
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1022 Main Street(Route 6A),West Barnstable M - 178 P-22
Property Address
Richard Hawkins
Owner Owner's Name
information is required for every 110 Sultan Point Road Barnstable MA 02630 October 14, 2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4 flowdiffusers
with 4 stone
❑ 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.):
Soil was sandy. Flows had a low water level present at the time of inspection. Checked stone and
found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time
of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of(liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.'" 1022 Main Street(Route 6A),West Barnstable M - 178 P-22
Property Address
Richard Hawkins
Owner Owner's Name
information is 110 Sultan Point Road Barnstable MA 02630 October 14, 2015
required for every ,
page. C41-rown 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.):
N/A
Privy(locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments note condition of
( o soli, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1022 Main Street(Route 6A), West Barnstable M - 178 P-22
Property Address
Richard Hawkins
Owner Owner's Name
information is required for every 110 Sultan Point Road Barnstable MA 02630 October 14, 2015
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
Zb '
❑ Elyo y
I Z? 2. = W
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1022 Main Street(Route 6A),West Barnstable M- 178 P 22
Property Address
Richard Hawkins
Owner Owner's Name
information is required for every 110 Sultan Point Road, Barnstable MA 02630 October 14, 2015
page. Citylrown 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: 6.8
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, -
❑ ca ators, installers (attach documentation)
® Accessed USGS database-explain:
SDW 252 Zone A 47.5' 1.6'adjustment
You must describe how you established the high ground water elevation:
Hand augered to ground water and found at a depth of 8.4'. Groundwater adjustment at the time of
inspection was 1.6'with an adjusted HGWL of 6.8' . Bottom of leaching at 3.8'was found not to be
located in the high groundwater elevation at the time of inspection.
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
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1022 Main Street(Route 6A),West Barnstable M - 178 P-22
Property Address
Richard Hawkins
Owner Owner's Name
information is required for every 110 Sultan Point Road, Barnstable MA 02630 October 14, 2015
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I
CERTIFICATE OF ANALYSIS g yy Pa e: 1
IQ Ml
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 12/7/2006
Richard&Lynn Vigeant Order No.: G0638929
1022 Main Street
West Barnstable, MA 02668
Laboratory ID#: 0638929-01 Description: Water-Drinki.ng-Watey-
Sample#: Sampling cation 10'Man St.W.Barnstable,MA ~/ Collected: 12/4/2006
Collected by: L.Vigeant Map 178 Parcel 022 Received: 12/4/2006
Routine
ITEM RESULT UNITS RL MCL Method# Tested
Nitrate as Nitrogen 2.0 mg/L, 0.10 10 EPA 300.0 12/4/2006
Copper BRL mg/L 0.10 1.3 SM3111B 12/7/2006
Iron BRL mg/L 0.10 0.3 SM 311113 12/7/2006
Sodium 200 mg/L 1.0 20 SM 311113 12/7/2006
Total Coliform Absent P/A 0 0 SM9223 12/4/2006
Conductance 960 umohs/cm 2.0 EPA 120.1 12/4/2006
pH 6.3 pH-units 0 EPA 150.1 12/4/2006
Sodium level is above the maximum contaminant level. Those on a low sodium diet may wi-t to consult a physic'an.
Approved By
(Lab Djy ctor)
2/ sc"�
ZE
V 1:.
W �
.. T
Cz r
c
MCL=Maximum Contaminant Level
RL = Reporting Limit Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
Town of Barnstable
�pf ZHE Tp�� -
yP o� Regulatory Services
Thomas F. Geiler,Director
+ BARNS'rABLE, •
9w MASS. Public Health Division
ATFp�,�s
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
t i
Office: 508-862-4644 Fax: 508-790-6304
January 16 2007
Mr&Mrs Richard�C. Vigeant
1022 Rte 6A
West Barnstable, MA 02672
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5
The septic system owned by you located 1022 Rte 6A,West Barnstable, MA was last
inspected December 4th 2006 by Patrick T Sullivan, a certified septic inspector for the
State of Massachusetts.
As the result of the subsequent review by the Town of Barnstable Plumbing Inspection, it
was determined that you inspection dated December e 2006 should be changed to
of 1995 TITLE 5 310 CMR 15.00 .
PASSED under the guidelines ( )
g
If there are any questions about this reminder, please feel free to contact the Barnstable
Health Department..
BARNSTABLE HE TH DEPARTMENT
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
is .
f �oF�HE T Town of Barnstable Q 21 1
Regulatory Service's.
o�
B"N
STABM ; Thomas F. Geiler,Director
9� MAM.
9.
A $ Public Health Division
Thomas McKean, Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax:` 508-790-6304
January 16 2007.
Mr&Mrs Richard C. Vigeant
1022 Rte 6A
West Barnstable,MA 02672
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5
The septic system.owned by you located 1022.Rte 6A,West Barnstable,MA .was last
inspected December 41h 2006 by Patrick T Sullivan, a certified septic inspector for the _
State of Massachusetts..
The inspection of your septic system showed that your system"Conditionally Passes"
under the guidelines of 1995.TITLE 5 (310 CMR 15.00) due to the following:
Sewer line exits the house.42" above the present water supply line. The minimal
setback is ten (10).feet per.the.State Environment Code.
You.have 2 years,to relocate the sewer line or the water line. Or,you have the option.
of sleeving the sewer line....
If there are any questions.about this reminder,please feel free to contact the Barnstable
Health Department..
B LE TH DEPARTMENT
Thomas A. McKean,R.S.; C.H.O..
Agent of the Board of Health
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1022 Rte 6A,West Barnstable,MA
Owner: Richard C.Vigeant and Lynn E.Vigeant
Date of Inspection: 12/04/2006
S TCH OF SEWAGE DISPOSAL SYSTEM
Pivide a sketch 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.
�• it
�2
in
f— , c-• TOWN OF BARNSTABLE
LOCATION SEWAGE41
VILLAGE �� I�a;rig Sf�� ASSESSOR'S MAP & LOT
i7 ar
INSTALLER'S NAME & PHONE NO.
.SEPTIC TANK CAPACITY /JOB �,� Sf• ti5
LEACHING FACILITY:(type)� ���✓ j, J
(size) l X R
NO. OF BEDROOMS P�OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
C 1
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Pt
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t�•-� � � � -- .fie�,:.s LE 4�L,
APPROM
COMMONWEALTH OF MASSACHUSETTS
S41wd Date BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphration for Diripooul Wl orko Tonotrnrt"ton ramit
Application is hereby made for a Permit to Construct ( ) or Repair ((.-f an Individual Sewage Disposal
System at:
Y ,
.............../0�1......�G/h...'S.."..---•--......--= ..........Y4/al... .-•---•----•-------•--•-•----------------•------.........--••--------.......-•---•................
// L -1`ion-Address- /_/ r Lot No.
Lc...O .a ...... Sl.41.5:�!4�_,S/f I /r " s fiL�i /-:' . .......
2 ..
w �o� /7. -n os�vc��Ih� 7 SC Adso� l�s
,.a ----••-•---•.........---••••--••--•••-•--...••-----••--•---••----•-------••----------------•-•---- -•-•••......---•----•••••.._ � .........................................
Installer Address
UType of Building Size Lot............................Sq. feet
�., Dwelling— No. of Bedrooms..................._-_---_.-__-___-__------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' 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.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date------------------......................
,.� Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
......................................................................................................................................................
0 Description of Soil...............................................--......................................................................................................................
x
U -••--•••••-•-••-••••-••••-•--••--------------••-•-•-•-......----•---•••------•••••----------------•--•••------•-•--•---•----------•--•----•••-•-••-•••-•------••-•-•-•------------.....................
x ••----•••-•..............................•-•-------••-••••---------•----••-----••-•----....-------•-------------•-- --...........;-•------ . --
U Nature of Repairs or Alterations—Answer when applicable.-.. �•._/`1�..__ �!.t.a ..:Jr.... �`r.K.. .--.��w......_.
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 Complian s be issued by the board of health. g
Signed ---------------- ...� < v. ......
Dare
Application Approved By ................ .'CN .-'�. ..... 3
Application Disapproved for the following reasons: .......................................... ................... ...... ......... .... ................................
........................................ ... ................................ . .................................................. .................... -.. ................... ........................................
Dace
PermitNo. ........... ......... ...... Issued .............. ......................................
Dace
No................-....... �7�-- 02'L K /Ficz......��U_. .vY
COMMONWEALTH OF MASSACHUSETTS j r
BOARD OF HEALTH II
TOWN OF BARNSTABLE
Xppliratinn for Di►pawl Wnrkg Towitrnrtiun runfit
Application is hereby made for a Permit to Construct ( ) or Repair ((.,)'an Individual Sewage Disposal
System at:
Locnlion-Address / r Lot No.
........... 4 os/•�..........Cs. _s .o _ ......................... 0 2 ............s --- .-..1...��... 'S.........
Add s
k4 FI.��G f, isvwulhu 7 sr
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
W
Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W -----------------------------------------------------------•-----------------------..........................----------•...------------........•-•-.......---
0 Description of Soil........................................................................................................................................................................
W
V -----------------------------------------•----------•--------------•---•---•---------------.........----------------------------------------------------•----------------............------.............
W
x ••--------------------------------------------------------------------------------------------------- ------------------------------------------- -----------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable__-P,,.J,,oJ,,0-__-. :?� Lj.........
.. ... - --- ------------------------•--------•---------------------.....---------------------------------................................
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 Complian, s begn issued by the board of health.
Signed ........... ._� ........................ .......�v....c1.3
Dare
Application Approved BY ................ .......... .. .......... ............... � — .......
Dace �'.
3
Application Disapproved for the following reasons: .. ... .................. ...................... . ............................ ..................................
. ............................................. ................. . ...........................................................------..................... .. ........................................
` ... ... Dare
Permit No. ............................... .................. Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(1:11,Qrtifirate of 10-11nmplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ............... ......... .............................
- ----- ......................... ... ... ................... ......-.
lnscallcr
at ....----..../..... .... I..�----__./�-Cl�e -S-1..,... ...- r......1. �z. 1?h -............. ......................................
has been installed in accordance with the provisions of TITLE 55 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -_-./.. --_. ""9T..-------- dated ------------------------................._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............ _.'. ..` fi-......._..... ---...----...__......._.... Inspector . ........ _...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Q /�c� TOWN OF BARNSTABLE
No.../.-.3.�--:/. 7 FEE.._3ca..:=
�i��r���tl3�nr�� �nrn¢tr�rtuan �rrmit
Permissionis hereby granted-------- .......C --------------------------------••-----------------------------------------•-••--••---•-----
to Construct ( ) or Repair ( ) an�idual Sewage Disposal System
at No....... . ........ &'_*........ .........u-_sq ........}��_ .�.:��-t "i ------
Strcct / 3_/—/?
_
as shown on the application for Disposal Works Construction Permi No�.__ _. ... Dated...........................................
•------------ -----
Board of Health
DATE.............. --... d-- --••--------------- ---
FORM 36508 HOBBS R WARREN.INC..PUBLISHERS