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0063 MORGAN WAY - Health
63 ,Morgan'WaY W. Barnstable P +9 A = 174 001064 o D �o In WN OF BARNSTABLE LOCATION Lc-'� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Liz<i L/(nG SEPTIC TANK CAPACITY t o0o q,A LEACHING FACILITYAtype) LQA&L, ©�j (size) UOU J�(�a�� NO. OF BEDROOAS_3 PRIVATE WELL OI<PUBLIC WATE `� BUILDER OR OWNER �7�ys �e Qw Co, -77/-Iog0 DATE PERMIT ISSUED: 31 L 9y DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No A— .fl i CI q f {/ No.. _....__. Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE . pphrativtt for Diripuiu! Wor1w Taimtrurtiun VarAit Application is rely ade for a I',�r to C onstruct (>�or Repair ( ) an Individual Sewage Disposal System��t: ✓ � t a ....__._. V� ' .........L-.o..-.-.' n-. id.s.................................... � r -rit . . .................................... ................ .... ....... I o .......................................... nwer ess %9'....... . .. ... ...I nstal Ier Address U Type of Building 4&"Vl Fcle� Size Lot-__! 47� ...Sq. feet �.. Dwelling— No. of Bedrooms.---_--.--------------------------------Expansion Attic ( ) Garbage Grinder (Ala) 114 Other—Te of Building g _-�t:.............. No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 04 Other fixture -----=------ ----------------- ............. _.. ._ . Design Flow............... . g P l� P Y Y 1..................�.y...�..�.gallons per per day. Total daily flow............................................gallons. GG Septic Tank—Liquid capacity t.��/gallons Length________________ Width................ Diameter--- ............ Depth................ Disposal Trench--No. .................... Width.................... .Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter----------.--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by............................................��..................___... Date..........._........ � � Test Pit No. I.°`. .._._minutes per inch Depth of Test Pit-----______......... Depth to ground water........................ f74 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ............ ----------- . .......................................-- 6 ..........•--..............................--•••---...... 0 Description of Soil-----•-•----•----•..... .0 ---- �1 -•------------------•--------•----------....-------------------------•-•----.......---•---•-•-- x w ........................................................................................................................................................................................................ ........................................................ .............................................................................................................................................. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ..------••-•--------••••--•-----------•-----•-•-•---•-•-------------•••------•------•--------------.•---------------•-.-.-•-----------------------•-••-----•-•_._...................................---- Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed2 ........................... ................. �e..........:...... ApplicationApproved By .....................:.......... ..... ..---------- .................................. .......... ................... .L.f. ..7.. ... ........... Application Disapproved for the following reasons: ........ -. -.................. ... .................................................... ....................... ................................................................................... . ... ..... .. . ..... ..- ........... ........................................ Permit No. 9 . ...............................................ra3g Issued Dare •-Jam'••-.••-..J�././�-�.e'' �,..�ljv-n/ti.-'/i/i 4.d`h r'•..ti...�_�•+v.4+ _..V.-. � ;.v. ....r___ __ ___... �,� � � _ _ _ � .. 11. � ` .__. _ - y v _ _ - _ si» 7 / f /. lv No...��_3- / l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ap.pliratiun for Di►,,pwial Works Tontitrnrtiun ramit Application is hereby made for a Permit to Construct ((/)/or Repair ( ) an Individual Sewage Disposal • to system t• 1/ / �� � .. . .....................................•. Location-:\d,I s's or Lot/Not ncr ` s, ,�/alter _ Address UType of Building !P U-U�" Size Lot..... ... c1-....Sq. feet Dwelling— No. of Bedrooms---------.��'_________________________________Expansion Attic ( ) Garbage Grinder (,t/U) ¢ Other—Other ofixt�uresilt--_...��---------------No. of --ersons------------------------..._Showers--•--•----•-- .............................) A4 YP g P ( ) Cafeteria a W Design Flow............... ---_�J__--_---____.__.___.gallons per pe @ per day. Total daily flow...-_.---___--�-_;_-----................gallons. � Septic Tank—Liquid capacity. gallons Length---------------- Width-_-__----_---__. Diameter.............._. Depth................ Disposal Trench--No. .................... Width.................... .rotal 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. 1.. -. .....minutes per inch Depth of Test Pit-----/6......... Depth to ground water.... �!�d . f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__...................__. �+ ------------------------------------ -•--•---•---••------•..._........... •••••••-------- •...... .... ..... •--------- _................ ....... ............... ... I•" D Description of Soil.......................-� U •--•••••••--•.....------•••-••••-•-•••---•--•••...........-•----••-•--••--••--•--•-••••.............••- UW ............................................--••••---------------------•------...........•-•••-•••-----•------•--------.....---...••-•-----•••••••-•••-•--•-•--•••••-•-•--••••-••-..........•-•........ Nature of Repairs or Alterations—Answer when applicable................................................................................................ .......•-•... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed /....... -------..._................ ..................:.................... // - Dace Application Approved B � -- - Dac Application Disapproved for the following reasons: ...................... ................................................. ....................................................... ............. .............................. .......................................... .......................................................................... ........................... . ................................... Dace PermitNo. ..... 3 r-�.3.g.................... _ Issued ...................................... ............................ Dace ._..��..:--�aam-.•,..-<..--r��..�...c,.®.:.�.or.-c+�-o r�c.3-oo.vrpA e.:ww>-ca me c.•-----ram.—.wits------:--Ur—m -----_..-..,.--r:,o THE COMMONWEALTH OF MASSACHUSE77S BOARD OF HEALTH TOWN OF BARNSTABLE (ITer#ifi ate of C11omylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V*') or Repaired ( ) by �./ V 1 -2-I-5cG L �_ ......... .. .. ............. ......... / M � _ �n � Insrdlc•r ............. - .. ..... �..�.... ............. . ...�-.. ..' ... ......... .......--........... .. .. .. ... 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. _-7.3._-..�����............ dated ....1-.(� ..7/9.?.......-._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ...- /" ....` .... -.................. Inspector _- ..... ------_ .- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE..... �t��rgsttl nr�� �,an,�tri•oxn �rrmit Permissionis hereby granted.......--..................................................................................................................................... to Construct (✓) or Repair ( ) an Individual Sewage Disposal System Street 93 as shown on the application for Disposal Works Construction P- mit No.................... Date .___.___1.��7_..•.�.._.__....•___ 9 ..- - •.__•-..-•..•............ �--� ••---� ............... 7�.w Boart�l of Health DATE..................................1 FORM 3850E HOBBS Q WARREN.INC..PUBLISHERS •f :N 'D'U-SI4W TATA B ,l7-a WAY�t&f-5- PAILS S.W/ Otis t W OO SE C TAWL � x��oiG� SAPb I f. DIgMA _ PIT_ (.. tba�+f h• �Z'S� Ibbb 5F X 7•s'r tl�o G�PGC b '� S� DMOM AR - '19 SF Ib -mmvat ,u 'S � _ 157 (.Art«.c earl: 4 t'',A +� 28 � Us �Mtlb 1aa _� Tk. .�, WLLIVAN .. 'AAlb >> Ito.29T33 `° $ u� 4Mr�t al Sa P'• loop 91 67 tom' � goic.y� ' q•� T . Foy SAL. � d a t� e �AIU AID FWr P �AV - �L. tx(p �a•C.d L.�• t CSMV'f JgAtl' T* Fvv)4**Tn-44 �r .OW9 INN COWL-. wru 'me 5 UUs IsPam• C* OF IDWOMNZ 40mm . 911.E � .. W T151 1:�44TCD W IU nwo d � q W xTErz I- Aye ifIv- PP0Ft%1D&J,&L L dUD Suture/t95 7* I�tj K4 trot' t*J AN 14 q1S hr' w a tr c--W41 N EetS 04.,M ro GSTA• R' PPapEV-T`f 'u'ue;. r�• � r-:-Tn�� i n i I,.IfI?I-1 �'S:SCE �66L-ST-d�S r � AA) 'OWN OF BARNSTABLE 4' LOCATION Lei I5(e wlc�,�ht, SEWAGE VILLAGE ASSESSOR'S MAP LOT I INSTALLER'S NAME & PHONE NO. Oi,5td11 YZC6 -L/6%0 SEPTIC TANK CAPACITY 1,006 alai d dV,5 LEACHING FACILITY:(type) LeAcl 9,1 (sue) 1, 0-0_0'5-I(a�s NO. OF BEDROO.AS �J PRIVATE WELL or<PUBLIC WATE BUILDER OR OWNER '7�-�yS� �� �d��..5 Cy. -77/-Ipy0 DATE PERMIT ISSUED:f/�"f 9`1 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i i I i I LYE. + �S E i ssr/ 17 J i '76 i i COVIMONW-EALTH OF U-1,SSACHUSETTS EXECUTIVE OFFICE OF EN`VIRON N E\r'L�T DEPARTMENT OF EN-V NXIENTAT, PROTECTTON oyM s�av / �z 00 / 0(� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUTNTTARY ASSESSA NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORT T , _ O 6 PART A CERTIFICATION Property Address: r✓1 67.4 6 6� Owner's Name: i C �,e- �» e� Owner's Address: -7 p,. e RYn �e OoZ66v' Date of Inspection: Name of Inspector-jplpase print) / -/ get — /OIe Company Name: Mailing Address: O pX / LcGfS A vim! !7oZ 6�a� Telephone Number�sp� 7�fC CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the info_rmation reported below is true; accurate and complete as of the time of the inspection.The inspection was nerforrned based on:rr,: _ tt training and experience in the proper function and maintenance of on site sewage disposal systems.i am a DEP `I approved system inspector pursua=Passes 15.340 of Title 5(310 CMR I5.000) he system:, - Conditionally Passes f � 1 Needs Further Evaluation by the Local Approving Authc�'c- -0 Fails ;- Inspector's Signature: / Date: The system inspector shall submit a copy of this inspection report to the Approving Author -(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 a -,o I 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 611512000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS--NIEN-TS SUBSURFACE SEWAGE DISPOSAL SYSTEM TNSPFCrjoN FOR_Ni PART A CERTIFICATION(continued) Property Address: fives Ns oa 6� Owner: 62►7✓1 e Date of Inspection: / —p Inspection Summary: Check _A,B.C,D or E/AL`VAYS complete all of Section D A. System ses: I have not found any information which indicates that any of the failure criteria described.in 310 CVIR 15.303 or in 310 C TR 15.304 exist.Any failure criteria not evaluated are indicated below,-. Comments: B. System Conditionally Passes: AV, SyOne 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. 7vvili pass. Answer yes;no or not determined(Y,N,ND)in the for the foLowing 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 t;=_11 tsass Lnspectioa 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. 7D explain: Observation of sewage backup or break out or high static water level in the distribution box Cue to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(r, th 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 tames a year due to broken or obstructed pipe(s). -1 ne s=__7em- ?1 pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: T;tlo Tn enenfi�n L _ e h r r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VO LUNTARY ASSESSAIENTSSUSSURFACE SEWAGE DISPOSAL SYST � � - Elvr�sp�cT��� roltzr PART A CERTIFICATION(continued) Property Address: li✓G'i Owner: /-Y-t y Date of Inspection: C. Further Evaluation is Required by the Board of Health: ./VConditions exist which require further evaluation by the Board of Health in order to determine if:he s,•ste,<n is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CNIR 15.303(1)(b)that the system is not functioning in a manner which will protect public health.safety and the environment: — Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier.if any)determines that the system is functioning in a manner that protects the public health.safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is whin 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, sutiplt-%ve11. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more mr-n a private water supply well**.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is 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: T;tl. Tnar antin L. .. /1 c Inn'_ L Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSAIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INTISPECTION FORINI PART A CERTIFICATION(continued) Property Address: 4 i Owner: i'y/✓Jhea Date of Inspection: I --a4 of p' D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes 'NTo/ _�Sackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool or _// Discharge or ponding of effluent to the surface of the ground or surface waters due to at, overloaded or /"logged SAS or cesspool — 11 Static liquid Ievel in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool ` Liquid depth in cesspool is less than 6"below invert or available volume is less than 112.day fio7, ✓_Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). \umbc �r times pumped ii any portion of the SAS.cesspool or privy is below ligh ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface rater supply or t ibutar-to a surface water supply. ' �y portion of a cesspool or privy is within a Zone 1 of a public wel?. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is Iess than 100 feet but greater than 50 feet tom a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis. performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/N'o)The system fails.l have determined that one or more of the above failure criteria e. st as described in 310 CTMR 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 1-5.000 gPd• You must indicate either"yes"or"no"to each of the following: ( �e following criteria apply to large systems in addition to the criteria above) y s a — the system is within 400 feet of a surface drinkirc,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—I-VTD 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 th eat. or an_srverea "yes"in Section D above the large system has failed.The owner or operator of any large syste�m con_ dead a significant threat under Section E or failed under Section D shall upgrade the system in" =: _h�„ _ 0 L,.,IR .15.304. The system owner should contact the appropriate regional office of the Department. T41. Tncncrtsn L c t c in n Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLL�'�T-ARY ASSESS1'IENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOPM PART B ? CHECKLIST Property Address: vJ /�O✓ Ci r� L,/� Owner: Iyl-1 ri n.-w/-e Date of Inspection: p2 Check if the following have been done.You must indicate"yes"or"no"as to each of the follwXing: Yes o �Vere ing information was provided by the owner,occupant, or Board of Heald, _ _' any of the system components , - ;mp s pumped out>.n the previous two a,,e.�s Has the system received normal flows in the previous two week period? Have larae volumes of water been introduced to the system recently or as part of thisCpecon ✓ _ W ere as built plans of the system obtain / p y d and examined?(If they were not available note as ti;_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 in - -th =� n spected io_ the co�diLo_, of the baf es 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 nth information on :he-oror~er maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determ:ned based on: Yes no xis.ting 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 apTro_jmation of-ah=szr ce is unacceptable) (310 CMR 15.302(3)(b)] Titlo Tneno tinn �n,m �I1 e/7nnn Page b of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLLTNT-A—RY ASSESS'TENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART C 7 SYSTEM INFORMATION Property Address: 63 �er Gvl tva Owner: #14ep ,It Date of Inspection: -p FLOW CO\'DITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actsal): DESIGN flow based on 310 Ci 15.203(for example: 110 gpd x_of bedrooms): \ nts:umber of current reside Does residence have a garbage grinder(yes or no):lVe Is laundry on a separate sewage system yes or no):� [if yes separate inspection required', Laundry system inspected(yes or no):/1_% Seasonal use: (yes,or no): - -- � �e� Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): AV Last date of anc occuP Y: G Lt r�C CONI L TERCIAL/IivDUSTRIAL Type of establishment: Design flow(based on 310 CMR15.203): gpd Basis of design flow(seats/persons/sgf(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: p2 00 6— t'✓h Oi- Was system pumped as part of the inspection(yes or no):X-V If yes,volume pumped: gallons--How was quantity Bumped determined? Reason for pumping: TYP F 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 mai tenance con ac-(to:ce obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components date insta e if lmown)and�p� o feorm. ation: Were sewage odors detected when arriving at the site(yes or no):A 0 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS EATS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI PART C SYSTEM INFORMATION(continued) Property Address: (�2 0" G H ,A Owner: h'I r e-m e Date of Inspection: c -0/J BUILDING SEWER(locate o?,site plan) Depth below grade:—� Materials of construction:_cast iron _4, PVC_other(explain): Distance frcm private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_�e on site plan) Depth below grade: l� 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 cony-of certificate) Dimensions: elf Sludge depth: Distance fro in top gf sludge to bottom of outlet tee or baffle: Scum thickness: Sj / // & �/ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto�}o outlet tee r I affle: How were dimensions determined: /e� P dg� Comments.(on pumping recommendations,inlet and atttret tee or baffle condition: structural integnitt�. liquid lei els as elated to outlet invert. vidence of 1 aka�Qe,etc.) _ / �t Y"J i✓1 ,/Ip nee c aT 7Y! ` v"le, c�v,lr `av� C✓ G / ✓L yr 01-750t7 (O4,ee 4f GREASE TRAP: /{/(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene other (explain): y 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, strucrwral as related to outlet invert, evidence of leakage, etc.): I Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLLT INNT_=ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAI, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �or rim (e /ej �� Owner: Y!'(✓in20. Ie Date of Inspection: --:oC;L 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 otrer(expiain): 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: y Comments (condition of alarm and float switches,etc.): f DISTRIBUTION BOX: (if present must be opened)(locate on site plan) de/p t,,,, Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal.any evidence of solids carryover, anv evidence of leakage into or out of box. etc.): / o L eve/ /Yr Svl c r L PUMP CHA-NIBER:/(/ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber;condition of pumps and appurtenances, etc.): Titlo Tncr�c tine T nrm AJl.�ljMn 8 Page 9 of 11 OFFICIAL ENTSPECTION FORM—NOT FOR VOLLTNT_-RY ASSESS NIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTTON FORM P A.Ra'C SYSTEM INFORMATION(continued) Property Address: 62 �O.r Q 0 Owner: /✓7 hheo► e Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: ie - CGs � Tvp VieachinQ its.number: .,P _ leaching chambers;number: r 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 vezetaton. etc.): LV CESSPOOLS: /y (cesspool must be pumped as part of inspection)(locate on site plan_) ?umber 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 or no): Comments(note condition of soil,signs of hydraulic failure,level ofpon&ag, condition of vegetarion. ;.tc.): PRIVY:4 (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 v get__07n rc.' Q . Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA P_A-RT C SYSTEM INFORMATION(continued) Property Address: Owner: 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 «ells within 100 feet. Locate where public water supply enters the building. -� �r1', i 3 j _q4 17 T41. G T,c-aPt; P,- 411:1')nn0 10 Page 11 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSES SAIEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT PART C / SYSTEM INFORMATION(continued) Property Address: 6 �Or �G,,,, (,✓C. / _ J r�sycb�e _ Owner: f�N►?•e,, Date of Inspection: SITE EX,�A? Slope Surface water Check cellar /O�0 i n Shallow]wells / . Nr Estimated depth to ground water S� feet o� ' 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: O -ed 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: Goo���w�-�. �, • la w�wn s• S i ' y J V ETA PAID( PLaW �t11at33DtP+� 5EMC T'AWL -jqo xo;vt-44C 1:� �(4fbSd _ PIT . 5iDEV�dLL �A= ;88 s� l� •Ea t 6Q RTER Igo Dom 3 IL MWXX Lai" 4f I�qc. 00 .+� g� T 1. Agy- CF -�--- �' -.rz Lr Fter �f�4N :I LL jVN : W. rl'7 is�7— �AV O S�C.d L. • ., TLA �� C* `DA OF DA1R N5t1►fu z d�tri �5 i rATiD W f u t tma, S�A't�• q`t3793 - DA XTE2 ( v 791( FMZ-%ICQAL LAUD Wemjte5 tom? �t� Ili ��' Gi.� � i���' 5O1 y tkqD o 5 'S ��txi. �! o ISTE.VIc tS MA44 , IPPLIC-AKT' 5og Boubfgd 4a�.I` wnm-4 �S:6f� S66L-ST- S - 00/ off`/ TROY WILLIAMS L - IS SEPTIC INSPECTIONS to Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRSjV 1 9 2002 DEPARTMENT OF ENVIRONMENTAL PROTF,CTION 'dvtN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A _ CERTIFICATION �. PropertN Address: 63 Morgan Way NAPr� West Barnstable,MA ©6 , Owner's Name: Evelyn Woodman PARC Owner's Addres.. C/o Carol McClay 153 Driftwood Lane,South Yarmouth, MA 02664 Date of Inspection:. November 13,2002 O Name of Inspector: •'Troy M. Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis, MA 02660 Telephone Number: (508)385-1300 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 to Section 15.340 of Title 5(310 CMR 15.000). The sv�tem Passes Conditionally- Passes Needs Further Fvaluation b) the Local Approving Authority Fails Inspector's Signature: f��(1 �_,; = Date: /l /i 3 /0 2- The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition Of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""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 saute or different conditions of use. Title 5 Inspection Form 6/15/2000 paee 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Morgan Way Owner: West Barnstable,NM Date of Inspection: Evelyn Woodman November 13,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be r aced or repaired. The system, upon completion of the replacement or repair,as approved by the Board o ealth,will pass. Answer yes. no or not determined(Y,N,ND)in the_ for the following statements. I 'not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whe er metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is i inent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by t Board of Health. •A metal septic tank will pass inspection if it is structurally sound, 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 high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or even distribution box. System will pass inspection if(with approval of Board of Health): brok pipe(s)are replaced o truction is removed distribution box is leveled or replaced ND explain: The system r ired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if ith approval of the Board of Health): i broken pipe(s)are replaced obstruction is removed ND explain: 2 " Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: 63 Morgan Way Date of fnsPectioWest Barnstable,MA ►►: Evelyn Woodman Nome her 13,2002 C. Further Evaluation isrequired 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. I. System will pass unless Board of Health determines in accordance with 310 CMR i5,303(10 that the system is not functioning in a manner which will protect public health,safety and the en A onment: 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 m sh 2. System will fail unless the Board of Health(and Public Water upplier, if any)determines that the system is functioning in a manner that protects the public heal ,safety and environment: _ The system has a septic tank and soil absorption sy in(SAS)and the SAS is within 100 feet of a surface %cater supply or tributary to a surface water s ply. — The system has a septic tank and SAS an he SAS is within a Lone 1 of a public water supply. The system has a septic tank and S S and the SAS is H ithin 50 feet of a private water supply well _ The system has a septic tan nd SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well t-. thod used to determine distance "This system passes if a well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatil rganic compounds indicates that the well is free from pollution from that facility and the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criter' are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 I Page 4 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Morgan Way West Barnstable,MA Owner: Evelyn Woodman Date of Inspection: November 13,2002 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 N1, Liquid depth in cesspool is less than 6"below invert or available volume is less than%: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. &I--I 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 l of a public well. &A Any portion of a cesspool or privy is within 50 feet of a private water supply well. — N/'s 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. lThis 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 S 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. l 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 de ign 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 criter' above) yes no — _ the system is within 400 feet of a surface drinkin ater supply the system is within 200 feet of a tributary a surface drinking water supply i _ the system is located in a nitrogen sitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water suppl ell If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered "yes"in Section D above the lar system has failed.The owner or operator of any large systerp considered a significant*Cot under Sect! E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owne ould contact the appropriate regional office of the Department. 4 I Page 5 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 63 Morgan Way Owner: West Barnstable,MA Date of Inspection: Evelyn Woodman November 13,2002 Check if the following have been done. You must indicate`yes"or"no"as to each of the following: Yes No information was provided by the owner. occupant,or Board of I iealtl, 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: 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 Pan C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] tti 5 Page 6 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 63 Morgan Way Owner: West Barnstable,MA Date of inspection: Evelyn Woodman November 13,2t,20W CONDITIONS RESIDENTIAL 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): 3 3u Number of current residents: -) _ Does residence have a garbage grinder(yes or no): Is laundn on a separate sewage system (yes or no):,A�o lif yes separate inspection required) Laundry system inspected(yes or no): ,v/,g Seasonal use: (yes or no): my Water meter readings, if available(last 2 yearsltsage(gpd)): Q, _ /t y ;y�r .,s oo = Sump pump(yes or no): nio —�— Last date of occupancy: . o a w;, COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.;c) _ __gpj Basis of design flow(seats/persons/s _ Grease trap present(yes or no):—,Industrial waste Holding tank presentNon-sanitary waste discharged to thei yes or no):Water meter readings, if available: _ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records S011rce of information: _ Was system pumped as par[of th nspec�tioon(yes or 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) _Tight tank _Attach a copy of the DEP approval _Other(describe):. Approximate aae of all components. date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):_Al,, 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: 63 Morgan Way Owner: West Barnstable,MA Date of Inspection: Evelyn Woodman November 13,2002 BUILDING SEWER(locate on site plan) Depth belu%% grade: /8 "/- Materials of construction: _cast iron _✓40 PVC -- other(explain):— Di,,tance• fron. private water supply well or suction line: �,2 Comments(on condition of joints, venting,evidence ut leakage,etc.): SEPTIC TANK: ✓(locate on,site plan) Depth below grade: 1 ' Material of construction:—Zconcrete_metal_fiberglass_polyethylene —other(explain) If tail: is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no)`.'_(attach a copy of certificate) Dimensions: _ 5 'k 9 'x G /o uo q.. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Z'S Scum thickness: .yoNrz 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Q r t 1 1 )F-v�-_,�in./=i.._._! `� .,K`�.�, �-r•✓ Lr✓a�f� v.. f"/cf T�t� ,�/wc. s. wJ✓/l.___1—.ur.JC�.�. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polye ene_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 outleZteeo ffle: Date of last pumping: Comments(on pumping recommendations,inlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leaka etc.): 7 f Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Morgan Way Owner: West Barnstable,MA Date of Inspection:Evelyn Woodman November 13,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of inspe ton)(locate on site plan) Depth below grade: __ Material of construction: concrete metal fiberglass olyethylene othpr(explain): Dimensions: Capacity: gallons Design Flo��: _ gallons/day Alarm present(yes or no).- Alarm level: Alarm in working Ord (yes or no): Date-of last pumping: '' Comments(condition of alarm and fl switches,etc.): DISTRIBUTION BOX: I'll (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 outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): Wo.. X.ihrl {�� w PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,conditio of pumps and appurtenances,etc.): i 8 Page 9 of III OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Morgan Way Owner: West Barnstable,MA Date of Inspection: Evelyn Woodman November 13,2002 SOIL ABSORPTION SYSTEM(SAS): ,�(locate on site plan,excavation not required) 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/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,'dondition of vegetation, etc.): LGti.�t. J,, cYA CESSPOOLS: (cesspool must be pZfailurejevel n)(locate n site plan) Number and configuration: _ Depth—top of liquid to inlet invert:---Depth of solids layer: Depth of scum lay er: Dimensions ofcesspool:Materials of construction:Indication of groundwater inflow(yes or Comments(note condition of soil,signs of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: -- Zailure, Dimensions:Depth of solids: Comments(note condition of soil,.signs of hydrel of ponding,condition of vegetation,etc.): I� 9 , Page 10 of 1 l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Morgan Way West Barnstable,MA Owner: Evelyn Woodman Date of Inspection: November 13,2002 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. 1341-6 . I � I - -J 0 U T 13A /o��y wcio ti 0 C n p 61-7 �t'ati �o Page I I of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Morgan Way Owner: West Barnstable,MA Date of Inspection: Evelyn Woodman November 13,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Sy feet Adjusted high ground water elevation —_feet Please indicate(check)all methods used to determine the high ground %user elevation: ✓Obtained from system design plans on record- If checked,date of design plan reviewed: _/Observed site(abutting property/observation hole within 150 feet Qf 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: _.�� Cam.(.✓`.- 6 a �-_._..._ -__L_ _._- � T�:.���f..�J''tii.4_• J u L. �-.� L(G.,.� b — --. .....-------- Jam _ �/� .�=•_.__�!'1.� 4 t.. S_w v....A jr.o Y3 This report has been prepared and the system inspected as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied, relating to the system,the inspection and/or this report. 11