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HomeMy WebLinkAbout0104 MOCO ROAD - Health 'U4 Moco Road W.-Barnstable P A = 195 014 - .. ti Tom. TQ .t}lF B' ABLE i Y�.LA �TA�'S i�TAl�r��:Pli�l�s NO ,a NQ �F88I��DAI .- S+dp�rstiort�Dtst�utcq$etw�n:F�o• - :! Bdaxin�m:,Acl.NNs�d�un+�i�'F�Ie�otlr�kBot�omofleachm�Fa�i�ty Fee Pine 11� aFF r` ell a dig aciii4y f ftt ire Est I; otis�tarq�ttbia3ElQfeta€ n►BfY� Fiat i fidge ciWetd andl�eacng sty �rctlaads exist ' G witbia 3QQfaet :teachttig f ) , �P ... ' : Feet' A � r o — 5LIO roawtc�C I d/ A- 1-3b3' ^i - as -3 - s Commonwealth of Massachusetts >a Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 104 Moco Rd Property Address t; Maureen O'Shea ; Owner Owner's Name , information is required for every West Barnstable ✓ MA 02668 3-12-20 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. A. Inspector Information 5/* ILIit r4 Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l 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 theproperty 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 3-12-20 1r pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 S Commonwealth'& Massachusetts Title 5 Official Inspection Form rli Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments ;> 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is West Barnstable MA 02668 3-12-20 required for every � page. City/Town - State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete•1, 2, 3, or 5 and all of 4 and 6. 1) System Passes' ' ® 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: System is in good working order with no sign of failure. ' 2) System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass" 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 Title 5 Official Inspection Form i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced' ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ 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 Commonwealth of Massachusetts , •. + r� Title 5 Official Inspection Form w:� i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20 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:'-t 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts 1� Title 5 Official Inspection Fora 01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I f�'%• 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No , ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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. ❑ ® t 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 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 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 �rI Subsurface Sewage.Disposal System Form -'Not for Voluntary Assessments 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 •3-12-20 - page. City/Town r 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 1 ® ❑ 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? ® ❑ Wasthe 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 cam,` Commonwealth of Massachusetts Title 5 Official Inspection Form �I�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 1 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3-2020 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts r Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments =1__� ; ' 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 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 occupancy/use: Date" Other(describe below): 3. Pumping Records: Source of information: Owner---pumped 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form t I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r U r 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20 page. City/Town 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: 1993 Were sewage odors detected when arriving,at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 36"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.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I Commonwealth of Massachusetts I Title 5 Official Inspection Form r�i Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is West Barnstable MA 02668 3-12-20 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 6. Septic Tank (locate on site plan): Depth below grade: 30"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: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 6" Distance from top of scum"to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts r� Title 5 Official Inspection Form ii, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd :=to - Property Address Maureen O'Shea Owner Owner's Name information is West Barnstable MA 02668 3-12-20 required for every page. City/Town 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 i nspecti on)(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 a 3� Title 5 Official-- Inspection Form YiI Subsurface Sewage Disposal System form -Not for Voluntary Assessments 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 '3-12-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. ' Distribution Box(if present must be opened)(locate on site plan): 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.): Good condition with water at working level with no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official fnspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Fora m �Icl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is West Barnstable MA 02668 3-12-20 required for every y r page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑, Yes ❑ No* Alarms in working orde-: ❑ 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. 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: 4-Infiltrators ❑ 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 c Commonwealth of Massachusetts ,w. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is West Barnstable MA 02668 3-12-20. ' required for every page. City/Town . State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infitrator field in good working order and holding 2"of water with no visible signs of back-up. 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 layer Depth of scum la p Y 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 3 Title 5 Official Inspection Form h► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20 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 Commonwealth of Massachusetts Title 5 Official Inspection Form 61 Subsurface Sewage Disposal System Form Not for Voluntary Assessments J. _ 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet..Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t M i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 1- Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form �"i' F�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - •w'�" 104 Moco Rd �..`, Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20 page. City/Town 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: 124 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: Original design plans show no groundwater at 12'. 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 r Commonwealth of Massachusetts Title 5 Official . Inspection Form a�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments fib`! 104 Moco Rd Property Address Maureen O'Shea Owner Owner's Name information is required for every West Barnstable MA 02668 3-12-20 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 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed s ® 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 i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts 34 Title 5 Official, hnspection Form r s SUbSU►face Sewage Disposal System Form - Not for Voluntary Assessments h7 104 Moco Road (main system). Property Address Renee Sherwood Owner Owner's Name information is West Barnstable required for MA 02668 May 6, 2010 every.page. City/Town State Zip Code Date'of Inspection D. System nformation (cont.) Sketch Of Sewage Disposal System: Provide a view of the.sewage disposal system, including ties to i 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 �. drawipg attached.separately li i Moco Road J3 7 41 25 �i 19 i- I jl i y Laundry Cesspool �I over.at grade. it H ! ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments iM 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Barnstble MA 02668 2-5-13 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. A. General Information jk� o 0 1. Inspector: - Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 16.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further.Evaluation by the Local Approving Authority 'Jee 2-5-13 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. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 it , Y � Commonwealth of Massachusetts f ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Barnstble MA 02668 2-5-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.)• Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 �a Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Barnstble MA 02668 2-5-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): r ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection a spect on Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Bamstble MA 02668 2-5-13 page. City/Town. 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: " S 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" be"low invert or available volume is less d' than Y2 day flow" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts ' i~ Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Barnstble MA 02668 2-5-13 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 MR 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 "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Barnstble MA 02668 2-5-13 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 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is W. Barnstble MA 02668 2-5-13 required for every 4 page. City[Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Well g ( y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 1-2012 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•11/10 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 „ 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Bamstble MA 02668 2-5-13 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: N/A 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Barnstble MA 02668 2-5-13 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: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 46"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): a Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 40"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: 1000 gal Sludge depth: 12" t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 t Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, M 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is Barnstble MA 02668 2-5-13 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) E Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is W garnstble MA 02668 2-5-13 required for every 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: f gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Bamstble MA 02668 2-5-13 page. City/Town State Zip Code Date of Inspection D. System Information cont. Y (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.): Good condition with water at working level and no sign of back-up from field. Pump Chamber(locate on site plan): Pumps in working order: ❑° Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: P y t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. garnstble MA 02668 2-5-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-infiltrators ❑ 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.): , Leach field in good condition with no sign of back-up into d-box or surrounding stone. 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-11/10 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 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is W. garnstble MA 02668 2-5-13 required for every page. City/Town State Zip Code Date of Inspection 7 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.): 'A , t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is required for every W. Barnstble MA 02668 2-5-13 page. City/Town 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 Wet 3 cy C-q-sa- '-�- aa' t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 1 Commonwealth of Massachusetts ` a Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd ' Property Address Renee Sherwood Owner Owner's Name information is required for every W. Barnstble MA 02668 2-5-13 page. City/Town 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: 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Rd Property Address Renee Sherwood Owner Owner's Name information is W. Barnstble MA 02668 2-5-13 required for every i 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE ^ CATION ® S # ASP VILLAGE ASSESSOR'S MAP&PARCEL NAME&PHONE NO.'g�Qr,r I C(c_ (3c.0 Ale x SEPTIC TANK CAPACITY 1000 LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER 5k-e-rUJ00 PERMIT DATE: C�DATE:n5P `S It to Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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) M Feet FURNISHED BY \ ♦ ♦ \ \\ ♦"\-\ \ \ \.4 \ ♦ \ \ ♦ \ 4 \ \ ♦ \ \ 4 \ \ 4 4 \ \ \ \ \ 4 \ \ 4 4 { { { f J J f f f f f J J F f f f f f 37 41 \ \ \ \ \ \ \ 4 ♦ \ , \ ♦ \ , J f J r r r r r r f r J J J J J r r r r ! fff J f f f f f J f J F f f f f f J J r F f { f f•J f f 19 ALaundry Ces: over at grade Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 104 Moco Road.. (main system) Property Address Renee Sherwood Owner Owner's Name information is west Barnstable required for MA 02668 May 6, 2010 every page. Cityrrown 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: A. General Information When filling out I I forms on the computer,use 1. Inspector: Only the tab key to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. t Company Name 189 Cammett Road Company Address Marstons Mllls MA 02648 City/Town State Zip Code 508.428.1779 SI 12855 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 or'site r sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340_of Title 5(310 CMR 15.000). The system: i ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ' p; 0 May 6, 2010 In pector's Signat 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage posal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is West Barnstable required for MA 02668 May 6, 2010 every page. Cltyrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMa 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumpng at this time, leaching system shows no evidence of surcharge or saturation. 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 ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 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 w 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is west Barnstable required for MA 02668 May 6, 2010 ` every page. Cltyrrown State Zip Code Date of Inspection fl B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is West Barnstable MA 02668 May required for y 6, 2010 every 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 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-09/08 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 w„ 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is required for West Barnstable MA 02668 May 6, 2010 every page. City/Town B. Certification (cont.) State Zip Code Date of Inspection 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"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•09108 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 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is, West Barnstable required for MA 02668 May 6, 2010 every page. Cltyrrown 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 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15ins-09108 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 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is West Barnstable required for MA 02668 May 6, 2010 every page. Cityr town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ® Yes ❑ No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): N/A Well Water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. 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-09/08 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 w 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is West Barnstable required for MA 02668 May 6, 2010 every page. Cltyrrown 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: Tank pumped 4 years ago. 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•09/08 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 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is West Barnstable required for MA 02668 May 6, 2010 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Compliance date: 6/28/93 Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ®40 PVC ❑.other(explain): P ) 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: 2' 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: 8.5' long x 5:2'wide- 1000 gal. Sludge depth: 4" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is West Barnstable required for MA 02668 May 6, 2010 every page. Cityrrown 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 26" Scum thickness 3" 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 101. How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank is not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ 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 15ins-09/oa Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 ,'<L -7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Moco Road (main system) Property Address Renee Sherwood Owner information is Owner's Name required for West Barnstable MA 02668 May 6, 2010 every 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: 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `M 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is required for West Barnstable MA 02668 May 6, 2010 every 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.): Box had a trace of solids carryover and no high stains, liquid level was found at bottom of single outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•09/08 / 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 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is required for West Barnstable MA 02668 May 6, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Four Infiltrators. ❑ 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.): Stone and soils were probed with no signs of saturation found 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•09/08 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 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name - information is required for West Barnstable MA 02668 May 6, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 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 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is West Barnstable MA 02668 May 6, 2010 required for y every,page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewagedisposal 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 Moco Road r / r r r J r r r r r ! J 37 41 ! 25 19 Laundry Cesspool over at grade. L r Commonwealth of Massachusetts Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is west Barnstable required for MA 02668 May 6, 2010 every page. Cltyrrown 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: 10+ 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: Pond at rear of property is more than 10 feet lower than area of SAS Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • 104 Moco Road (main system) Property Address Renee Sherwood Owner Owner's Name information is West Barnstable required for MA 02668 May 6, 2010 every page. Cltyl own 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 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 CERTIFICATION MAP S Property Address:. � PARCEL � LOT i Owner's Name: ` Owner's Address: Date of Inspection: c �," V E) Name of Inspector• please pr'nt). � �Cr�' �,T. QN�''t DEL Company Name: �� 002 Mailing Address: ® � 'c' • ,r is dARNST Telephone Number: �d (:rH DE 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 function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant 7passes ection 15.340 of Title 5(310 CMR I5.000). The system: Conditionally Passes Needs Further Evaluation 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 appravi.ng authority. Notes and Comments ****This report only describes conditions at,the time of inspection and under the conditions of use at that time. This inspection does not address how the system will.perform in the future under the same or different conditions of use. , Title 5 Inspection Form 6/15/2000 page 1 e S Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: L�1 Owner: �. Date of Inspection: -p_ ei Inspection Summary: Check A,B,C,D or E/:ALWAYS complete all of Section D A. System Passes: Jam' 4I have not found any-information which indicates that any'of the-failure criteria described in 310 CMR 15303 or in 3l0'CMR 1_15.304.exist.Any failure criteria not evaluated are indicated below. Comments: ` B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved b the Board of Health will ass. pP Y p Answer yes,no or not determined(Y,N,ND) in the 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 assapproved by the Board of Health. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water-level in the distribution box due to broken or obstructed.pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are,replaced obstruction-is removed ND explain: . 2 Page 3 of 1'l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORIVi PART A CERTIFICATION(continued) Property Address: Owner::\a. Date of Inspection:J d C. Further Evaluation is Required by the Board of Health: Conditions.exist which require further evaluation by the Board of Health in order to deteimine.,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 systems 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 wit.zin 50 feet of a bordering veoetated.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 tEnk 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 we'1 water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A,-Copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL,INSPECTION FORM NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: j�A Owner:. Date of Inspection: /�1.)6)00_ D. System Failure Criteria applicable to all systems: You must indicate".yes" or"no"to each of the following for all inspections: Yes NoJ. _ L 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 L/ clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded orclogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or,available volume is less than %2 day flow Required:pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ' of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Anyportion 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 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.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large systemahe system must serve a facility with a*design flow of 10,000 gpd to.15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply 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. .4 Page 5 of 1.1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART B CHECKLIST Property Address: �) �� (� Owner:o Date of Inspection: Check if the following have been doze.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? L/ Were as built plans of the system obtained and examined?(If they were not available note as N/A) V _ Was the facility.or dwelling inspected for.signs of sewage back up? - Was the site inspected for signs of break out V" — Were all system components, excluding the SAS, located on site Were the septic tank in 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 _V" _ 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 Systenv(SAS)on the site has been determined based on: Yes no — 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(3)(b)] 5 . Page 6 of 11 OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS . .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION Property Address: :� ) yn J 4� � Owner:. Date of Inspection: .2 _ FLOW CONDITIONS RESIDENTIAL t-/ Number of bedrooms.(design): .. �Number of.bedrooms(actuaI): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Q_ - , Does residence.have.atgarbage grinder(yes or no):✓A& Is laundry.on a separate sewage'system (yes or no):� „if yes separate inspection required] Laundry system inspected(yes or no):tQ a Seasonal use:(yes or no l (Z® Water meter readings; if available(last 2 years usage(gpd)): �'/ ���✓� Sump pump(yes or no): ,0" Last date of occupancy: - � COMMERCIAUINDUSTRIAI� Type of establishment. Design flow(based on 310 CM11.15.203): gpd Basis of design.flow('seats/persons/sgft,etc.); Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system'(yes or no):- Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records :Source of information: Was system pumped as part of the inspection(yes or o):✓_- If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping- TYtg OF SYSTEM eptic tank,distribution box,soil absorption system tingle cesspool _Overflow cesspool _:Privy Shared system.(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative teclmology..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): A p oximate age of all omponents,date,installed(if nown)and source of information: f Were sewage odors:detected when arriving at the site(yes or no): 6 Page 7 of I I OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C e Owner: 0 Date of Inspection: �� BUILDING SEWER(locate on site plan),.. Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): _ Distance from private water supply well or suction line: Comments(on condition of joints;venting, evidence of leakage,etc.): SEPTIC TANK: locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass 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: (w Sludge depth: /® Distance from top of sludge to bottom of outlet tee or baffle: Z 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: How were dimensions determined:, sCl(/➢�� �?�"T' Comments(on pumping recommenZfftions, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evideup of leakage,et � /o � - 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 L Page 8 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued] Property Address: 10V Owner:•2� �'� Date of Inspection: lei C' a TIGHT or HOLDING TAN} (tank-must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(expWn): 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 Tioat.switches, etc.): . DISTRIBUTION BOX: /(if present must be opened)(locate on site plan) Depth'of liquid level above outlet invert/�� � Comments(note if box is level and distribution to outi'ets equal, any evidence of solids carryover, any evidence of a akage into or out f box, etc.): PUMP CHAMBER (locate on site plan) Pumps in working order(yes or no): Alarms in'working order(yes:orno):. Comments(note condition-of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Property Address: JAI AI Owner: Date of Inspection: �� SOIL ABSORPTION SYSTEM (SAS):. (locate on site plan,excavation not required) r If SAS not located explain why: Type leaching.pits,number:_ leaching chambers, number: _leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alte'rnative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc 7Y VA� (16ulm 4Z�U&A 203�'Z�oly�-ft" 6WI"5, t,.N CESSPOOLS: ,/ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 5 Depth—top of liquid to inlet.invert: Depth of solids layer: Depth of scum layer: u1 __ Dimensions of cesspool-..-,,?, , c " Materials of construction: indication of groundwater inflow(yes or no): mments(note condition f soil,.signs of hydraul,' failure,level of ponding, condition of vegetation etc.): a� t / AL PRIV3; (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 Page 10 of 11 OFFICIAL-INSPECTIONFORM=NOT FOR YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ad /o A WWI Owner: e2� Date of Inspection:. SKETCH'OF SEWAGE DISPOSAL SYSTEM Provide 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. o o1 9 d 10 Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART-C . J SYSTEM INFORMATION(continued) Property Address: / Owner Date of Inspection: e /c;)iQ0®c)- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Z -1 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: �hecked with local excavators, installers-(attach documentation) Accessed U.SGS database-explain: You must describe how you established the high ground water elevation: Ll 11 Permit Number: Date: Completed by: 94_�z'!3 HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Jfi°41 �/ �' L� ��� Lot No. Owner: ��, �f� �0�/ Address: Contractor: &� `/� Address: ,✓�i,��/���' Notes:. STEP 1 Measure depth to water table1,3411 to nearest 1/10 ft. .................................:............................................ .Date month/day/year -STEP 2 Using Water-Level Range Zone and.Index Well Map locate site and determine: OAppropriate index well................................. .................. OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" . determine current depth to water level for index well ........................... 1 L �Z %ig month/year STEP 4 Using Table of Water level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) �y determine water-level adjustment............................................................................................ T STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ............................................................................................................. Figure 13.--Reproducible computation form. 15 i 9 _ i TOWN OF BARNSTA,BLE � LocasTzoN /y,a c o IPc� si;w�GE ViLO GE A.SSE.SS®Tt'S M"&LPT �. INSTALLER'S rtFtl►J k' ®PdE I+IO �4 LEALCIM4G,./}►CIB (sire} { N0.0� PEITDA, . CgMi ,IR.S�iC AATB: 5epnrxtaon W4.. ltno Maximum A4djustrcJ GtauYadwatec Table to tl t}ottbti Supply Js it yti f.c. :hin ) aciliry f f' ►y ^re19s gist cce . a� aiti�oc�vitllin BOA�eet'af le�actiiri�Cacii►ty) �-�—.....�._..�----... cit,j j.jf Weiland and Lcaciung lraci)iV(�an aellandy st ee ti+fitla�aa'�Qa feet i naitiin�iuci.1y OJ �n CVCr^ �4CK oy A-/-363" 13P f C'y-sa' TOWN OF BARNSTABLE LOCATION .r� ® /e�. SEWAGE# Z01,e11?1.7z G I!ILLAGE e dl j�Q��L® ASSESSOR'S MAP&PARCEL",, -®/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IWO LEACHING FACILITY:(type) y- a�f t`"//j /�j�/ (size)- NO.OF BEDROOMS 3 OWNER L4eeoemd PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 14 'i No. Q / / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for ;Disposal *pstem ConstCUition Permit Application for a Permit to Construct( ) Repair((✓)/Upgrade( ) Abandon( ) ❑Complete System [F/Individual Components les'7sor's iioon—Address o of No.lO(J oC� �/ Owner's Nampe,Address d Tel.No. Map/Parcel (c�• Q'I�I�P�S �/le /L1�iWL�C� 5-kllwl®e Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. r -7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sigqrk Date Application Approved by %W Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. ' � Q ee 4 THE COMMONWEALTH OF MASSACHUSETTS Entered n computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplicatlon for Disposal *pstrm (Construction permit Application for a Permit to Construct( ) Repair(1/) Upgrade( ) Abandon( ) ❑Complete System individual Components Loc�tioon-Addrrte�ss or,Lot No.��/� f Owner's Name,Address, nd Tel.No. Assessor'sM p/P�ar7c'el ( I '/"6'J��`C'Y//{� Ree&e Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: 7 Dwelling No.of Bedrooms ! Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank � ��/� �"i1'/j Type of S.A.S. l Description of Soil i Nature of Repairs or Alterations(Answer when applicable) [' Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in .. a accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. _... .-------- / Sig Date Application Approved by Date v Application Disapproved by Date for the following reasons Permit No: Date Issued /U - - - ------------------------ ------------ -- -------------- ------------ - -------_ ------- THE COMMONWEALTH OF MASSACHUS -TTS '`� ° BARNSTABLE,MASSACHUSETTS\ Certificate Of Compliance THIS IS TO CE IFY,that the n-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) r Abandoned( )mo�b//y ©/- 4 G� / y ll at ��� ,/iIC�C"C� 42�I �S1di1�Geen constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a(() 17/dated %v Installer Designer #bedrooms N A Approved design flow ) gpd The issuance of th's pe it shall not be construed as a guarantee that the system wil . do as design d. i Date 33 (o Inspector rh No. 2 o I�1 " �� Fee dC� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS i disposal pstem Construction Permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at { and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. i Provided:Construction must be completed within three years of the date of this permi. n� Date l/�//U Approved by �� r/�/ i New Page 1 http://www.town.barnstable.ma.us/assessing/2010/HMdisplay.asp?... TOWN OF BARNSTABLE � LOCATION _ Al 44D SEWAGE # 9,-�r--d-6f i VILLAGE (�tJ, ��i l� ASSESSOR'S MAP& LOT 195--0/y INSTALLER'S NAME & PHONE NO. go707lLGTI C'b.��Lq,'~ i SEPTIC TANK CAPACITY 1'oyo LEACI4ING FACILITY:(type) (size) 7 -y NO. OF BEDROOMS VAT WED OR PUBLIC WATER BUILDER O DATE PERMIT ISSUED: (olialky DATE COMPLIANCE ISSUED: - 2 y "✓_3 i VARIANCE GRANTED: Yes No 37 1 Ioq j' wet 1 of 2 III 6/8/2010 2:29 PM TOWN OF BARNSTABLE LOCATION ' ley adZ 04D SEWAGE # 9,2r w VILLAGE ' f�t1. / 5 1- ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. eU10701-01- SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 7 � NO. OF BEDROOMS VAT WM OR PUBLIC WATER BUILDER.O DATE PERMIT ISSUED: kzlo�y'. e /DATE COMPLIANCE ISSUED: ` 9-3 VARIANCE GRANTED: Yes No) t u y a_ No..., Fx$.... � ... THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH Barnstable'Conservation DePOMIOnt TOWN OF BARNSTABLE pplirttta ffl for Di►ipotial Works Tnnitrnrtiun rautit Application is hereby made for a Permit to Construct ( ) or Rcpair C>4+ an Individual Sewage Disposal System at: ••--- -------••••-•••----••••--•--••-.........-•-•-•---•-••••..............•-•...._.._..-••.....---•-_.. / /�� Lc....•Address...... G or Lo_t I�1o. r - �� ... � ..................................... ...:................ J....._.... owner ddr s 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. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ � 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........................ -------------------------- ••. --------------------------.-_-_-..-____-....----.-•--------••---•----_---- 0 Description of Soil..........�:--.c.........�_?✓�..'7/yIN.....�--•---.....�i��$'a1-�.. f �� ---------------- •-••••......--•----•........ V .....•---------•-----------••••••...............••......--•-•-•-•••-......-•- W UNature of R pairs or Alterations—Answer when applicable.._./_✓�.�!-�'��..__._ _ .Q... 7 -�_ 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%h s een i su by t e board of health. Signed ------- ---- - ----------------- ----- -- ----- -- . . ...4 ..... .. Application Approved BY � ... .. .... ............. ................................. ..-..Q.C�...—p a) Dare Application Disapproved for the following reasons: ...... ...... ... .................................................................................................. ......................................................................................... .... . . ............--...............---................._................._.............. .................-...................... Dare PermitNo. ..............)-.13--.- d;... . .c. .............. Issued ............................................................-....... Dace -THE COMMONWEALTH OF MASSACHUSETTS BOARD O.Fw HEALTH TOWN OF BARNSTABLE | ' Application is 6cre6v made for u Permit to Lonsrmt ( ) or Repair an Individual Sewage* - System at: Disposal GarbageLocition-Address or Owner -,Address M Installer Address 44 Other—Type of Building -----__--. No. of persons............................ Showers ( ) -- Cafeteria ( ) ~� Other fixtures ----------'-.--.----............................................................................................... Design Flow.................i��..............gallons per person per day. Total daily 8o~--. -' . 1:4 Septic Liquid .. Diameter--.--- Depth................ ' Disposal Trench--No. ......... ....... Width........7__?!!�' �otal Length--' Total leaching area....................ag f t. Seepage Pit No------- Diameter...... ............. Depth h6mw i,lec-._-._-_ Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) '- Percolation Test Results Performed bv.......................................................................... Date........................................ 0.4 14 Test Pit No. l................minutes per inch Depth of Test PiL--..--'- Z}cyt6 to ground water........................ Test Pb No. 2................minutes per inch Depth of Test Pit-------- Depth to ground wuter------.-..-. | . . --._-------.-_'-.-_--�-._- 0 � S�- 0��� Description- ` - ---~-'--�----'---------'---------- -r''---~----'^~-............................... .................................... _----___-'--_.-.-_-_'._-'--__-_------'-'---___--'__-_ :1.1 .---_-----'—'_-----'''--'-'-----._-.---.''''''''---.- U Nature of Repairs or Alterations—Answer when applicable_ Q__ ......../ AN 0 Agcccoeoz: 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 e n i su by the board of health. igne Da* -�^ ApplicationApplication~~ ^,rp^~`^~ By ���----------------------' --���=` ^^�e.......'� Date Date ---------------- THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired Installer has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .......��3, _7.......... dated ...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � ------ BOARD OF HEALTH TOWN OF BARNSTABLE to Construct or Repair,(_�.-an Individual Sewage Disposal System Street r— as shown on the application for Disposal Works Construction Permit Dated.........4'..afl�.Y3...... THE COMMONWEALTH OF MASSACHUSETTS / 95,- O/ v _____________ Board of a=uh FORM 36508 HOBBS&WARREN.INC..PUBLISHERS ------------------- � ' �