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HomeMy WebLinkAbout0068 MORGAN WAY - Health 68 MORGAN WAY, W. BARNSTABLE A= 175 025 0 0 a u o r Commonwealth of Massachusetts ��� ���Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 68 Morgan Way s ; Property Address r Robert and Donna Paolini , Owner Owner's Name / information is West Barnstable V MA 02668 06/16/2020 !required for every page. City/Town State Zip Code Date of Inspection a Inspection results must be submitted on this form. Inspection forms may not.be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return key. Company Name 52 Rivers End Road Q Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails �z 2? 06/17/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �w Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I; .............. 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 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: This 3 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-box feeding 2 leaching chambers with stone. At the time of the inspection there was apx. 2" of ponding water in the chambers and no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N FIND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form i r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 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 ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Morgan Way V� Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way V� Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 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 flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: In 2019-80,000 gallons were used and in 2018-63,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form += lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way V� Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 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: 01/19/2018 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): " Depth below grade: 21feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and it came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �C V � 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"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: H-10 1000 gallon Sludge depth: 311 Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Ali Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 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 inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 68 Morgan Way V Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 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? El Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of lllquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. The D-Box was viewed with a video camera. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 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 order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 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: two ❑ 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 Commonwealth of Massachusetts �v ,(,A Title 5 Official Inspection Form Iii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 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.): At the time of the inspection there was 2" of pnding and no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form III l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is West Barnstable MA 02668 06/16/2020 required for every 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form< Subsurface Sewage Disposal System Form -Not for Voluntary Assess mentsRK 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is West Barnstable MA 02668 06/16/2020 required for every City/Town State Zip Code Date of Inspection page. 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 P►2;Zl :.. A I 3 I t t: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 t5insp.doc•rev.7/2612018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. 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 �v ,lp Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Morgan Way Property Address Robert and Donna Paolini Owner Owner's Name information is required for every West Barnstable MA 02668 06/16/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Town of Barnstable r V h Department of Regulatory Services i Public Health Division Date L-Vi 019.��� 200 Main Street,Hyannis MA 02601 IAIt� Date Scheduled Time Fee ft 100 — Soil Su)i/t/ability.Assessment for Se ge Disposal Performed By: /YJ / Witnessed By: ' f 4QCAT�IQO.�N fz GENERAL INFORMATInyN Location Address /_O A A i.-�/.'+' � l p//,/p-v� Owner's Name J A I l 1 o` SS IA s �U�S V�-C• l Address 11 drt�V V Assessor'sMap/Parcel: 's/z 5 G Engineer's Name OANJJD NEW CONSTRUCTION` PAIR Telephone# 7- q-,Q/Q�VV_�� Land Use �/� Slopes(%) �`J�q/�,Surface Stoners I4 Distances from: Open Water Body > V V ft Possible Wet Area 1 6aft Drinking Water Well>/soft Drainage Way ft Property Line >/D ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ��V I/qn7 7-8 r Parent material(geologic)C O 1 "`(�Wh"" "ke th to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date Time Observation t Hole# Time at 9" Depth of Perc ( Time at 6' Start Pre-soak Time @v Time(9"-6") End Pre-soak �—fL Rate Min./Inch Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTIC\PERCFORM.DOC I . r "f DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel tOq DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ther Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel Z AIIA DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Graven Flood Insurance Rate May: tv Above 500 year flood boundary No A Yes_ Within 500 year boundary No— Yes Within 100 year flood boundary No Yes_ Death of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervimpaterial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pery ous material? Certification J- � I certify that on (date)I have passed the soil evaluator examination approved by the Department of Erotection and that the above analysis was performed by me consistent with the required trainnd xperience described in 310 CMR 15.017. Signature Date r VV- Q:\SEPTIC\PERCFORM.DOC TOWN OF BARNSTABLE LOCATION morgQo t k0 14 SEWAGE#-zoIII - y YMLAGE Baxr-% ASSESSOR'S MAP&PARCEL IS15- 2 S INSTALLER'S NAME&PHONE NO. �xec�yci-�lior� �I�1'1 O S� SEPTIC TANK CAPACITY I p7O 90. LEACHING FACILITY:(type) SOOga l�r_�2� (size) ,3 x 25 x Z NO. OF BEDROOMS 3 OWNER v PERMIT DATE:_1 -Z 2. 1*� COMPLIANCE DATE: j0 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 Al— I y A2. Z I $ " 32' A3' 3q' F"ron� day - 3�'S" O 3 TOWN OF BARNSTABLE LOCATION nongan t..0 SEWAGE# 7_0JJ - 455 VILLAGE W. Roxf\ ASSESSOR'S MAP&PARCEL 1145 - 2S INSTALLER'S NAME&PHONE NO. Q 1. 3 -i'lrl- oL53 SEPTIC TANK CAPACITY /000 c,0.) LEACHING FACILITY:(type) TppaaI C.C. �2� (size) 13%25 xZ NO.OF BEDROOMS 3 OWNER v p PERMIT DATE: IZTz 11*I COMPLIANCE DATE: �� 0 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 Al- 81- 1 y AV ,B2" i s's „ M' 3q' From 33- 2,) B A nil d3y ' 3° s O 3� 0 f No. I� � / Fe / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliCAtion for Disposal *pstrm Construction 3pPrmit Application for a Permit to Construct( ) Repair(N() Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. & r O rgQ(I 21M� O er's Name Address,and Tel.No. Assessor's Map/Parcel '' "� rZ.. ��'n `�"�s `50k,3L 7-16 Y-4, Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Lgt13 k-xcavat on -JOV-107-06 Type of Building: ' ''� Dwelling No.of Bedrooms \J 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 J� gpd Plan Date / q (., 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) 2,0 2 N 2G 600 LaC M6P�r� 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 Boars' al ,Sign l 17 Date Application Approved by """ "-"' Date 2-&242tv 1' Application Disapproved Date for the following reasons Permit No. Date Issued �Z�ZZ�/�(?L 7 No. /9 Fe THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: z Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(\() Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. &9_,tlO i qan 04 l/ Owner's Name Address,and Tel.No. Assessor's Map/Parcel t� '7 Q `5dk 3G 7 J6 Y�, Installer's Name,Address,and Tel.No. `' Designer's Name,Address,and Tel.No. SIB � XCavahign 50� h�7-o�5 �ah�er y��V �►�u-��y-/r�� 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 3 gpd Plan Date I q 1(71 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) Z N 2G 500 Cdz V- -b o t 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 Boarddf eal 1. gn X/t� Date 121 r Application Approved by . Date /2 :Z_ Zo 1 Application Dspproved Date for the following reasons Permit No. l- L/5 y Date Issued_/Z12Z&O/";;t- --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned (�( )by �i 1� r X �rt�/ca((&n at l� O A a(� �1 l/ }JT�lTl ri (��r ee5 constructed in accordance with the psi s of Title 5 and Pe for Disposal System Construction Permit No,7a-+—qT3` dated 17 Z" Zor's.- Installer 1� Q t Designer #bedrooms Approved design flow 0 gpd The issuance of this pe it shall of be construed as a guarantee that:the system will functio d si ed. Date \Inspector -------------------------------------------------------------------- ----- --------------------------------------------------------- co No. 2,n0 — y Fee �/ . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to C nstruct( ) Repair( ) Upgrade( ) Abandon System located at v 0 V W 13ams-la—bLe 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. Provided:Construction must be completed within three years of the date of this perm' . Date /7 lz Z /7[D I t Approved by Town of Barnstable Regulatory Services Richard V. Scali,Interim Director * 1WWSTMM MASS, Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: I-►%-1 Sewage Permit# 2o1r1 -qSS Assessor's Map\Parcel 19S -25 Designer: 0a-%jc- TLo,1 =-A" Installer: B� ,B Ej(Ca�A�oy\ Address: Box R 1 Address: 1 y TcaS cEN 1-Q �armo��Dor-1 Fo rr.si 4o.-1 c_ } On `'Z- -22- 1'9 t3 EXeau-1 i o n was issued a permit to install a (date) (installer) septic system at rq o rcka„r\ wog based on a design drawn by (address) eve �laher-��.r dated (designer) X I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructedliAkTpliance with the terms of the I\A approval letters (if applicable) Ali`' f ass ts''~ DAVID D. f LAHERTY,JR. taller's Signature) No. 1211 O'ISTER�O I'llg��C#TAR%P� (Designer' ign e) 2 (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUII.T CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc I Ln C3 Ir C3 OFFICIAL s y. _ 111.11- Certified Mail F /�A EXtI'�,um ces&Fees(check box,add fee as appropriate)r:j �f�y alum Receipt(hardcopy) $ r3 []Return Receipt(electronic) $ PO rk 3. O []Certified Mail Restricted Delivery $ Herd, D Q ❑Adult Signature Required $ ,Q p �q []Adult Sign re Restricted Delivery$ 1 Pos g � Total Postage aodWees Ln Sent To C3 sr�aat- t o%x f�[n 1 • City, to .ZI � �N 'Ii��Q/'� I�►.7 --------------------- Oalo(oi� :rr r rr rrr•, Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail labeq. for an electronic return receipt,see a retail e A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted ililetum receipt for no additional fee,present this , delivery. 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Adult signature service,which requires the '-U ■You may purchase Certified Mail service wigs signee to be at least 21 years of age(not —9 First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service: Adult signature restricted delivery service,which n Certified Mail service is notavailable for requires the signee to be at least 21 years of ago+ International mail. and provides delivery to the addressee specified:y ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retaiq. 4 of Certified Mail service does not change the a To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark If you would like a postmark on I-'! ■For an additional fee,and with a proper this Certified-Mall receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office—for F-, the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion l.A of delivery(including the recipient's'signature)", of this label,affix it to the mailpiece;apply I" You can request a hardcopy return''receipt or-an. appropriate pgstage;and deposit the mailpiece. r; electronic version.For a hardcopy return receipt,. ,, • _ -ri complete PS Form 3811,Domestic Return,.)�3.). ':SAY�S j � Receipt:attach PS Form.3811 to your mailpiece; IMPORTANT:Save this receipt for your records. 4 fat d:a .. a i , u ; :) 's•t`i. �' 't, .ter Ps Form 3800,April 2016(Reverse)PSN 7536-02-000-9047 ® Complete items 1,2,and 3. 7=R' e re ® Print your name and address on the reverse Agent so that we can return the card to you. ❑Addressee ® Attach this card to the back of the mailpiece, y(Bryn d Name) C. D t of Deli ery or on the front if space permits. rC 1. Article Addressed to: D. Is delivery address different from.item 1? ❑Yes If YES,enter delivery address below: p No f�OIISS � Gt�h L. 4.n W3 Mdirrn9446k, an Gray Ww II I�IIIDI IDiI Ipl I II II II i I I IIIII111181I IOI II III [40d Adult ult Signature Restricted Delivery ❑Registered Mail Restricted Mail 9590 9402 1933 6123 1799 55 ❑Certified Mail Restricted Delivery ei�m Receipt for ❑Collect on Delivery Merchandise 2.—.Articlp_N2imhpr_LTransfpr_fmm camlr_p_Inhali- ❑Collect on Delivery Restricted Delivery ❑Signature Confirmation ail ❑Signature Confirmation 7 015- 1730 000.1 ,4,9910 i 3.9 0 5 I i I jail Restricted Delivery Restricted Delivery' o) ( j� orm 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt LISPS TRACKING# Y r�:Gles�„I . Ft' 9590 9402 1933 6123 1799 55 United States •Sender:Please print your name,address,and ZIP+4®in this box* Postal Service Town of Barnstable (O.,O,—,D,. Health Division 200 Main Street F Hyannis,MA 02601 I \ I ��,nl�llujy+il1.l fillfilill: f ��►�ram, Town of Barnstable Barnstable AB-AmmiRegulatory Services Department �a� ilj Re p �,srASM g1 9g3e " . � Public Health Division rf�MAYA 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1730 0001 4990 3905 September 22, 2017 ROUSSEAU, ALAIN L &ANN M 68 MORGAN WAY WEST BARNSTABLE, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 68 Morgan Way, West Barnstable, MA was inspected on 09/08/2017 by Brett Hickey, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action: PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\68 Morgan Way West Barnstable.doc Town of Barnstable + aaacrisrr t Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA'02601 Office. 508-862-4644 Richard Scali,Director FAX 508-790-6304 Thomas A McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES TO*REPAIR FAILED.SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An`x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground w . ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE 1 YEAR DEADL (Static hqui eve in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Single'Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level,<12"below inlet (per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q\SEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments to t 68 Morgan Way 47M 1re45 Property Address Alain Rousseau Owner Owner's Name73 information is required for every West Barnstable V/ Ma 02668 9-8-17 page. CityfTown State Zip Code Date of Inspection �J Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form.. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation r� Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-8-17 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•3/13 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is West Barnstable Ma 02668 9-8-17 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 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: 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 68 Morgan Way M Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis ,and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- ,10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 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): 854gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way M Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (9p ))� Detail: 2016- 102,000gallons 2015- 108,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 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: Owner-last pumped 3 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way M Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1994 Were sewage odors detected when arriving at the site? El Yes ® No Building Sewer(locate on site plan): Depth below grade: 27 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feeetet 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: 1500gallons per plan Sludge depth: 1' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 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 24 Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 12 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 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: NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 page. City/Town 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 Over Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was in poor condition at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ 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, condition of vegetation, etc.): Leaching was in hydraulic failure at time of inspection. Liquid level was over inlet invert in leach pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Morgan Way M Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 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 Front A B 2 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is required for every West Barnstable Ma 02668 9-8-17 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: >12 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: Aug-4- 1994 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '9M 68 Morgan Way Property Address Alain Rousseau Owner Owner's Name information is West Barnstable Ma 02668 9-8-17 required for every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION . -J—D`"j i� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 68 Morgan Way W. Barnstable Owner's Name: Alain & Ann Rousseau Owner's Address: Eg Mnrgan Way Date ollnspection rr.I (34. Name or Inspector:(please print)_William E_ . Robinson S r. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA Telephone Number: l S 0 81 7 7 5-8 7 7 6 CERTIFICATION STATEMENT 1 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.1201 a DEP approved system inspector pursuant to Sec n 15340 of Title 5(310 CMR 15.000). The system: 7 Passes I Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: .-- Date: 4�-� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board Heaithi* , 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 f4l"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 I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Morgan Way W. Barnstable Owner: Alain & Anri Rousseau Date of inspections Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste Passes: have I he not found any information which ch 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. S tne em Conditionally Passes: or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the. for the following state explain. ments.If"not determined'please 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 indicatn that the tank is less than 20 years old is available. ND exp in: bservation of sewage backup or break out or high static water level in the distribution box due to broken or obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appro al of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND xplain: The system required pumping more than 4 times a year due to broken or obsizucted pipc(s).The system will pass ' pection if(with approval of the Board of Health): broken pipes)are replaced obstruction is T=vrd ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Addressi__ 68 Morgan Way W. Barnstable Owner: Rousseau Date of Inspection: x C. urther 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 fail' g to protect public health,safety or the environment. 1. ystem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the ystem 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 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.i 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 froul 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: 3 Page 4ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Morgan Way W. Barnstable Owner: Alain & Ann Rousseau Date of Inspection: —G D. System Failure Criteria applicable to all systems: You must indicate`yes".or"no"to each of the following for all inspections: Yes No _J,/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 /logied 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 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number i� 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 I00,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 56 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 al 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.l _Y (YestNo)The system fails.1 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: arge Systems: Tobe onsidered a large system the system must serve a facility with'a design-flow of 10,000 gpd to 15,000 gpd' You m (indicate cither"ycs'or"no"to each of the following: (The fol owing 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 I of a public water supply well If you ve answered"yes"to any question in Section E the system is considered a significant threat,or answered ..yes"i Section D above the large system has failkd.The xmmer or operator of arty large system considered a upgrade significant threat under Seaton E or failed under Section D shall pgr the system in accordance with 310 CMR 15.30�.The system owner should contact the appropriate.regional office of the Department. 4 Page 5 of.l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_68 Morgan Way -W. Barnstable Owner: n Reusseau Date of Inspection: 7,0 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? t/ Have large volumes of water been introduced to the system recently or as part of this inspection? ._/'I/Wcre 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? V Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tan}: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 Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 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: 68 Morgan Way W. Barnstable Owner: Date of Inspection ';Z 6' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x R of bedrooms): 3 4-6 Number of current residents: Does residence have a garbage grinder(yes or no):.-A-v Is laundry on a separate sewage system(yes or no):774)[if yes separate inspection required] Laundry system inspected(yes or no): a Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 5 — 9 9, 0 0 0 Sump pump(yes or no):,v 2U04 — 8b, 000 Last date of occupancy: —A`•-U L COMMER IAL/INDUSTRIAL Type of es blishment: Design flo (based on 310 CMR 15.203): gpd Basis of d sign flow(seats/persons/sgft,etc.): Grease tr p present(yes or no):_ Industria waste holding tank present(Yes or no): _ Non-san tary waste discharged to the Title 5 system(yes or no):_ Water eter readings,if available: Last dale of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: �� Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: Qallons--How was quantity pumped determined? Reason for pumping: TYP 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) _lnnovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all comp vents,date installed(if known)and source of information: 0 Were sewage odors detected when arriving at the site(yes or no): 6 OFFICIAL INSI1EC'1'I0N F0101-NOT FOR VOLUNTAIIY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 110101 PART C SYS•I M 1NF011111AT10N (continued) Property Address: 68 Morgan Way W. arns a e Owner: Alain & Ann Rousseau Date of Inspectlon. UUILDI G SLWLII(locate on silt plan) Depot b low grade: Materi s of construction:_cast iron _40 PVC_utlrer(explain). Dista c from private%vale(supply well or suction line:_ Cun»�enls(oilcondition of juints,venting,evidence of leakage,cic.): SL'PTIC TANK. r/(Iocate on site plan— plan) Depth below grade: lb � Material of construction:_cuncrctc metal fiberglass Jurlyedq•Iene _othcr(cxplain) — — If sank is nsetal list age:_ Is age cunftrnted•by a Certificate o(C certificate) umpliance(yes or nu):-(attach a copy of b `. l V% Dimensions: 'L; 02 ' Sludge depth: .. Disla,ce from lop of sludge to butlunp of uutict Ice or bafllc: Stunt thickness: ,/-3— Distance front sup of scum lu pup of outlet Ice or bafllc: s f Distance Qotn bo,unt of stun,to bu,om of outlet tee or baf lle: I lo%v were dimensions descnnined: Continents(on pumping rccunune„Jatiuns, inlet and uutict Ice or bafllc cunJiticn, sUuctwal integrity,liquid as related to outlet ntvcrs,evidence of leakage,etc`): � lei cls l Z7Tj � J - tw GIIEASE TRAP. Iucalc un site plan) DcPUt bcloty grade: Material of constru ion:_____cuncrctc metal lberglass—pulycllt)•lcnc _outer Dimensions: Scum thickness: Distance (roll,to of stunt 10 top of outlet Ice or bafllc:_ Distance Gorn b Ilion,of scum to buuum of outlet tee or bafllc: Date of last pu�111)ulllpmg ping; Cununcnts(o iccurnlncndatiuits,inlet and uullet ice or bafllc cunditiu:t, stnuomal integrity, litluid Icvcl, as rclalcd to u06 ins•crl,c►•iticim of Icakarc,cic.): 7 ]'age 8 of I 1 OFFICIAL INSPECTION FORNI " NOT FOR VOLUNTARY SUDSUILI�ACL SL\1'AGL DISPOSAL SYSI*EM INSI'h,C-I ION FORM t S PART C SYSTEM INFOR WriON(cunlinucd) Property Address: 68 Morctan Way —W Ra rn tAb-1e Owner: T i�,�� Disle of Inspection: — J—6--4 seau TIGHT or 110LDIN TANK:_(ta,tk inust be pumped at lime of ill silt clion)(locate on site plan) Dcpth below grade: Matelial of construe on:__concrete_metal_fiberglass_�iulyethylerie othei(explain): Dimensions: Capacity alluns Ucsign Flow; —gallons/day Alann present Ics or no): Alarm level: Alann in lvutklll utdcr Date of last p inptng: 6 V'cs or nu):— Conuncnts(yondiliun of alarm and nuat sssilclics,cic.): DISTRIBUTION BOX::(if presatl.ntust be opcncd)(locatc oil site plan) pl ) Dcplh of liquid level above ouilcl invert: Conuncnts(note i(box is level and distribution to ouilcis equal,any cvidctice of solids cairyover,any evidence of leakage into or out of box,etc.): PUMP CIIAIUBCIt: (locate on site plan) Pumps in working dcr(ycs or no):_ Alarms in%%.Orkin tirdcr(.)•cs or no): Cununcnts(nut condition of pump chamber,condition of pumps and ahpuitenances, etc.): Page 9 of 11 OFFICIAL INSPEC TION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Morgan Way .W. Barnstable Owner: Alain & Ann .Rousseau Date of inspection: 'tea d�6 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,condition of vegetation, etc.): c �b cr-E� !�}j0 L-- cJ 7 Zi yL../'G �,b o � �,. y� �� ✓ CESSPOOLS: - (cesspool must be pumped as part of inspection)(locate on site plan) Number and con rguration: Depth—top of quid to inlet invert: Depth of solid layer: Depth of scu layer: Dimensions f cesspool: Materials)/ aterials o construction: Indication f groundwater inflow(yes or no): Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i PRIVY: ocate on site plan) Materials of onstruction: Dimension Depth of s lids: Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Morgan Way W. Barnstable Owner: Alain & Ann Rousseau Date of Inspection: of 7 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. J Ll �l )31 v ` 3 10 Page l 1 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _68 Morgan Way W. Barnstable Owner. Alain & Ann Rousseau Date:of Inspection: r —° SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water /i 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) F/Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must d cribe how you established the high ground water elevation: "O 11 �-� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 68 MORGAN WAY W. BARNSTABLE ''1 S Z� 1---I n, Name of Owner EVERETTE KASHER A� Address of Owner: SAME p Date of Inspection: 6/27/99 Name of Inspector:(Please Print)JOHN GRACI C I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) �`} J UoA/ Z 3 1999 Company Name: n/a Opi Mailing Address: n/a IyO Telephone Number: n/a �� A 1 E Z 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is Needs Further Ev I tion By the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:6/31/99 The System Inspector shall bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:6/27/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nta 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced nM The system required pumping more than four 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 revised 9098 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:5/27/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nia_(approximation not valid). 3) OTHER nta revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:5/27199 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Wa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:5/27/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)[ X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:6/27/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):2 Total DESIGN flow: 1M Number of current residents:2 Garbage grinder(yes or no):N12 Laundry(separate system)(yes or no): NIQ If yes,separate inspection required Laundry system inspected(yes or no):JM Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): MQ Last date of occupancy: D& COMMERCIAL/INDUSTRIAL Type of establishment: n& Design flow: nLa gpd(Based on 15.203) Basis of design flow: WA Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): XQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) Wit Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: NONE System pumped as part of inspection:(yes or no):11LQ If yes,volume pumped nta_ gallons Reason for pumping: Wa TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1994 Sewage odors detected when arriving at the site:(yes or no) tYQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:6/27/99 BUILDING SEWER: (Locate on site plan) Depth below grade: i E Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: Wa Comments: (condition of joints,venting,evidence of leakage,etc.) Wa SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No n/a Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: L" Distance from top of sludge to bottom of outlet tee or baffle: 3_ Scum thickness:1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 1Z How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: n/a Scum thickness: n/d Distance from top of scum to top of outlet tee or baffle:ji/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:6/27199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nta Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) D& Dimensions: nta Capacity: n& gallons Design flow: nLa gallons/day Alarm present: NO Alarm level:..nLa_ Alarm in working order:Yes_No_: NO Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) D& DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND, SYSTEM IS FUNCTIONING PROPERLY PUMP CHAMBER: MO (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n& revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:6/27/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: WA Type: leaching pits,number: ONE PIT leaching chambers,number: -ILA leaching galleries,number: jaLa leaching trenches,number,length: n& leaching fields,number,dimensions: nLa overflow cesspool,number: nLa Alternative system: Wit Name of Technology: jVa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS UNDER DRYWAY,SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: _ (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: n1a Depth of solids layer: nLa Depth of scum layer. Wa Dimensions of cesspool: Wa Materials of construction: Wa Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection)n1a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:nLa Dimensions:n1a Depth of solids: Wit Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:6/27/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a s� From ('�ch C (d b D A17 as AC ay y � `fr 88 �s �as revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 MORGAN WAY W.BARNSTABLE Owner: EVERETTE KASHER Date of Inspection:5/27/99 NRCS Report name: nLa Soil Type: nLa Typical depth to groundwater: nta USGS Date website visited: nla Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 oa-� Commonwealth of Massachusetts Executive of E nvironmental Af f airs DEP D epartment of , e Environmental Protection V.� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �`9�'�' _. CERTIFICATION Property Address: — Address of Owner: tA,c5ro.�� (if different) Date of Inspection: Name of Inspector: Michael D eD ecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420 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 inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system -X Passes ---- Conditionally Passes --- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s Signature: t� Date: ` A k Aq The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer,if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6C6 t,�ozi�YN-,3 Owners : l oa,,. , Date of Inspection : INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM PASSES: - I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B) SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If "not determinated", explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration ,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). ----- broken pipe(s) are replaced ----- obstruction is removed ---- distribution box is levelled or replaced ---- The system required pumping more than four 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 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : fora t-looia+,o 0 wner : \�� Date of Inspection : ,t WAl e C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: --- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system-is failing to protect the public health;safety and the-environ= ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETYAND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IFAPPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has aseptic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: G8 Wko2c�-vj � Owner: 1�0 Date of Inspection : �� I%%I61�� D) SYSTEM FAILS (continued) -- 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 over- loaded or clogged SAS or cesspool. --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I 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 ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4-8 wa�� Owner: Date of Inspection : E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : --- 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. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: % (Ao%tc�",v- wzx � Owner: Ikeal-\ D ate of I nspectio Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x-None of the system components.have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with NIA. --x The facility or dwelling was inspected for signs of sewage back-up. .x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components,excluding the Soil Absorption System, have been located on the site. ---x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees,material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods --•x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: o� Owner: Q� Date of Inspection: 11 61ct RESIDENTIAL: Design flow: '33 ® gallons Number of bedrooms : 03 Number of current residents: Q Garbage grinder (yes or no) : NC: Laundry connected to system (yes or no):u�v_S Seasonal use (yes of no) Water meter readings, if available: aw`n, Last date of occupancy : COMMERCIALANDUSTRIAL : Type of establishment: Design flow : gallons/day Grease trap present: (yes or no) Industrial waste holding tank present (yes or no) : Non-sanitary waste cischarged to the Title 5 system (yes or no) : Water meter readings, if available : Last date of occupancy : Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of��'rntf rmation �?}StS.IM...tS...u�! ?.f..W...tJ�,�... � System pumped as Fart of inspection (yes or no) :.......N.S�..... if yes, volume pomped : .................... gallons Reasonfor pumping :............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: w Owner: k4r,9, Date of inspection: 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) --- Other (explain)........................................................................................... A PROXIMATE AGE of all components, date installed (if known) and source of information ......:.....a.y s. ..................................................................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no).....t.�.i. SEPTIC TANK : ... (locate on site plan) Depth below grade: ...(Z... Material of construction: ...k.. concrete ....:.... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: !C.l Sludge depth:....0........ r Distance from top of sludge to bottom of outlet tee or baffle:......3.4................. Scum thickness:.....©............. it Distance from top of scum to top of outlet tee or baffle: ........... .b....................... Distance from bottom of scum to bottom of outlet tee or baffle:.....L. ................. Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in relat' nAoutlet invert,structur integrit , eviden a of I�e etc.). n NQ . . W��� 41 L►� i .,........................... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of inspection: GREASE TRAP : . L)'Vocate ch site'planl Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... ...:........:............................................................................................................................. Dimensions:............ .................. Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................ ................................................................................................................................................ ............................................................................I................................................................... TIGHT OR HOLDING TANKS:...0.0.... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ...:........:................................................................................................................................... Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee. condition of alarm and float switches, etc.) ................................................................................................................................................ ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Ck r Owner: Date of inspection: DISTRIBUTION BOX:.."-�_S (locate on site plan) Depth of liquid level above outlet invert:.-. 9.Q . -- Comment: (note if level and distribution eg4al evidence of solids carryover evidence of leakage into 0 out of box,etc. ... . ... ,. PUMP CHAMBER:.. CS.... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ SOILABSORPTION SYSTEM (SAS):...le. ...... (locate on site plan, if possible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ ................................................................................................................................................ Type: leaching pits, number: ................ leaching chambers,number:........ leaching galleries, number:........... leaching trenches, number , length:..................... leaching fields, number, dimensions:................... overflow cesspool, number:.......... Comments: (note ond' ion of soil, nr4' f h draufic failure, level of po ding, condition of vegetation SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 6�3 N �.mo, d'" Owner. u��J Date of inspection: CESSPOOLS:.... ... - (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................. PRIVY : VO.... (locate on the site) Material of construction: ................................... Dimensions: ...........**"*...- Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.). ................................................................................................................................................ ................................................................................................................................................ SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : Owner: Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' kz i INy- �56 - �z DEPTH TO GROUNDWATER: rt Depth to groundwater: ..n.%feet Method of determination or approximative: .................................... ................................................................................................................................................ ................................................................................................................................................ TOWN OF BARNSTABLE SEWAGE # YILLAGE W. A-ftt ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY � ®� LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �,� ,� �_ � ` -, G eV('` - V � � � � `� . . __ � TOWN OF BARNSTABLE L!JCATION (,S r., w ,.in SEWAGE # 9y -y�U � VILLAGE J � ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. RkC1gA qI -t SEPTIC TANK CAPACITY � LEACHING FACILITY:(type) kv (size) , NO. OF BEDROOMS PRIVATE WELL 09ZUBLIC WATER BUILD OWNER Q.S.%0.4LQ-e'-'," Q a-Oki DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No s2 No..ry.....Wo- FEB ;. 11W.......... THE COMMONWEALTH OF MASSACHUSETTS p BOAR® OF HEALTH ..•.--•..�d...e...J....._....OF........ .1. 1.ST .i .�- Appliration for Disp.ati al Works Tomitrurthnt Prruti# Application is hereby made for a Permit to Construct (y%r Repair ( ) an Individual Sewage Disposal System at: ...M.Q Q . �... A- .................................. ..• ' � ...l..o � . . ion-Addreds or t N ........----••. e owner 1 Addre Installer �� Addr�ss UType of Building ] Size,Lot___ .........Sq. feet Dwelling No. of Bedrooms..._ ... ____ -_-;. __Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Buildi g :........................... No. of persons----------------------------- Showers ( ) — Cafeteria ( ) � Other fixtures ......................................................--------------..............................• ••• •--------------...............•--•••-- W Design Flow............. ........:.....................gallons per person per day. Total daily flow............... q...............gallons. WSeptic Tank—Liquid capacity 4i.2 --gallons Length.)_O'.6___. Width___-?� "*- Diameter________________ Depth.,5:..I..''. x Disposal Trench No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......I.......... Diameter.._. ... Depth below inlet... ....... Total leaching area.jp�•._:-r.,� 4. e� Z Other Distribution box ( LIr Dosin tank ) `-' Percolation Test Results Performed b � !6 �__..G.............. Date..lX 11-sT a y.. Test Pit No. 1......2-------minutes per inch Depth of Test Pit....1,5.!........ Depth to ground waterf-loYtf..0...... 44 Test Pit No. 2......2.......minutes er inch Depth of Test Pi ___..�. _........ Depth to ground water-W 0.Q........ J � -J�p o�L4s� c .x►��ct�.. �2 0'-5' tapso.�ct'�c.x�sarc., . ` / 0 Description of Soil-------•----------------cH?60t&.--• h(Wl jL i.irj....LAtYnc-------------------5--.-12--4.G-�J ML�we!J !��2d�C� V ..........................................................W-�E..._............_...._........................_..._..._.......-- T.. .�.P1t��UI� ro LARL-+fs S('dx l E, Z-f ...... ---•--------•-- Q ---•••......•-••••- V 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 Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued b the board f l�ealth. Signed ••. . ••--• _... ....... Application Approved BY . •--•--•-- /Date ..........Application Disapproved for the following reaso .. -------------------------------- �..^... J --•-----------------------------------------------------------------------------•-----------•---------....--U..---------•-------------------------------------------------------------------------•---•-/ Date ...................... Permit No....... _~:.. LJ. Issued. Date No.f......5_v � _.._ , Fxs....... � �........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ! C (tee` OF `1, at .................. ...............................• Appliration for Disposal Works Tonstrur#iun Pumit Application is hereby made for a Permit to Construct (,4,)--or Repair ( ) an Individual Sewage Disposal System at J ... --..-.- ...i{,r� € S..r. .Ri ..1 �( d s�,� ..:�� \1 ....� ........ ��t r..K '•r �g.. ' 4 L-ocatlon—Addre s or L�t No, (\rat r -} - r Ow er 1 ...... 3 .J.. s:.r_ Installer Address U Type of Buil in "'"" ` g Size Lot__. .: r!.........Sq. feet �-, Dwelling—No. of Bedrooms.......... .:.............................Expansion Attic ( ) Garbage Grinder ( ) r Other a —Type of Building .............----------..... No. of persons............................ Showers - -•-•-•-Cafeteria Other .................................................... .( -•)- fixtures .....-•----•--- ---•-•-•...---•--------------•••--._._... -, ea.........._ lons. W Design .Flow.............._-.=........................gallons per person per day. Total daily flow..............:__..:.....__ ______gal WSepptic Tank—Liquid capacity--: �--Lgallons Length.':'_:....... Width.-w-........__. Diameter________________ Depth_ M x Disposal Trench—No. .............r..... Width.................... Total Length..................... Total leaching area.........:..........sq. ft. Seepage Pit No....._. ._...:___.. Diameter...M4_.:CJ._.._. Depth below inlet s_:x I Q....... Total leaching area.. :' ,�.gq�i z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed ":` t TM ' f " i = m a + I ' ................ ---•••• ......-•--.._. Date ' ...Z. ; Test Pit No. 1.......ir......minutes per inch Depth of Test Pit..... _......... Depth to ground water. :. .:-------� P3 Test Pit No. 2..... minutes per inch Depth of Test Pit-----J.:a ......... Depth to ground water 4 ."................4 r tl-, - x. .... ( ..f.... ODescription of Soil.............................1 !a_._ 6 tf G e) 4 i �r ! t 4 I A� - 1...... �_ ` ------. •--•--• ---•`•---- W 1 1fia 3.................. w t• sL4 <- iar vw^:R ... ............................................................................ %_r^__ ............................. V 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 Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board.of 1 ealth. r Signed ............. Application Approved B l J� Date) Application Disapproved for the following reaso `--- 3e .1 ---------••-•-----------•-•--• ......l. ..............•-----...........••--•---••-------•--•-----•------------.....--------•-----...-•----............ ��// QQ Date PermitNo.......?../......�-.FJ-J --------------- Issued.........----------- ..----•---•--•......•-•-•----•• Dattee � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ::: 'l.' '.................OF............. :;`�"!t• !� y�: - ::..:....:.............. QTrrtifirttfr of Toutplianrr THIS I TO CERTIFY, Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.........• •-.- .1 That the I�n i 0�� :?C, t't _ Installer t ..(/. has been installed in accordanceJwith the provisi of ?' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A GUARAN EE THAT THE SYSTEM WII. FUNCTION SATE CTORY. DATE.... ar � ............... ... ..... Inspector.._.. r ................. r•-,- V � THE COMMONWEALTH OF.MASSACHUSETTS ✓" BOARD OF HEALTH r y_ ..................................OF...�. � �..� ,� x .- _ ........................................No ................ . . ....... Disposal Works Tnns#r ' n Vrrmit ; y{ toConstruct , ) or Repair ) an c ....................... ........... ..............•--- •-••---•-••-................._....................•---.............. Permission is hereby ranted............. Individual Se , l Disposal System �- - P at No........ ..6--•.5.................................`'=y2 C., ' V ' .. Street NN as shown on the application for Disposal Works Construction Permit NO�� ._ Dated.......................................... % ^tom Board of Health DATE.............. ------ ..._.. ... FORM 1255 HOBBS & WARREN: INC.. PUBLISHERS rr � TOWN OF BAMSTABLE LOCATION V 0)0( WAG`E�# VILLAGE �-� B R'S MAP & INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 � Y � l5' 9e TOP OF FOUNDATION. COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM,PROFILE BROUGHT TO WITHIN 6"OF FINAL GRADE Flaherty Environmental Services EL. 60.0' EL. 58.0' (not to scale) INSP. PORT W I 3" OF GRADE CLEAN SAND P.O. BOX 81 2" of to " DOUBLE•WASHED EL.58of Yarmouth Port, MA 02675 . " CAST IRON or EQUIVALENT PEASTONCOR GEOTEXTILE 774.994.9166 FILTER FABRIC ~ IW � MIN. PITCH 1/4" PER FOOT k. a"SCHEDULE 40 PVC PIPE 4" SCHEDULE 40 PVC PIPE '. VENT IF REQUIRED FLOW LINE (first 2'10 be level) 8' 3.8% _i 5' loh <. EL. 55.7'f L.EXISTING 14" —� ®•Q C7 O(�p.�y Q.; o 'O O�O Q oo°o°o°oc EL. EXIST. —�� —► °°0°°°°°°°0 ° �� �LJ� �'� = O 60606060E 0 0 0 0 0 0 0 0 0 0 0 \EL. 55.0' 4 000000 0000000 0000o0o0c 3(' EL. 54.53' o 0 0 0 0 0 o n �� O o00oo0o0c , EL.54.7' ° 0 0000000000000 �E10L=.JLJ ��L�J. o°o°°°°°c 2 0 GAS BAFFLE EL. 54.5' 0000000000 000000 0 0 0 0 fir, o 0 0 0 0 0 0 0 ° a a•. A 010.0000C EL. 52.5' (H-20 DBOX) 0.5'CRUSHED STONE OR SOIL ABSORPTION SYSTEM MECHANICAL COMPACTION (2) 500 GALLON H-20 CHAMBERS 1000 GALLON SEPTIC TANK 5' (DATUM: ASSUMED) (EXISTING) 3" toll' DOUBLE WASHED S ONE WITH 4'STONE AROUND IN A — a 12.83'W X 25.01 X 2'D CONFIGURATION EL. 47.5' BOTTOM OF TEST HOLE EL. 47.5' LOCATIONMAP USGS ADJUSTMENT: N/A GROUNDWATER ELEV: N/A N TH IOS,>S, p 'Qaay o. �s LOT 159 W aa� LOCUS 60 16,581 SFt g Morgan n EXIST. LP / GARAGE 5 LP NTS DECK ���YH OFhZgSS EXISTING 60 �p� D 1 / 56 /P H-i 7, 3 BR -' / / H-2 y DWELLING `o o F TY,JR ,r EXIST. ' 00 121 O / 1000 GST e� C1 ..... /STE /TAR\ 8.5' BENCHMARK: I O �./ TOP OF FNDN \ EL, 60.0' Z SHED DATE:1211912017 REVISED; 11.3' 154.27' a 14.7' SITE AND SEWAGE PLAN Sa FOR B & B EXCAVATLON, 1NC./ F ALAIN ROUSSEAU 56 } 68 MORGAN WAY SCALE : 1 " = 3 0' WEST BARNSTABLE, MA REF PB 439 PG 15 PAGE 1 OF2 ...................... . ..... . ..... .. . .. ................... ........ ... .. ..... .... ....... .......... ................ ..... ................................. .... ... ..... ....... . ............................................................................... ...................... ..................................................................................................................................................................................................................................................... ........................................................................................................... GENERAL NOTES DESIGN CAL CULA TIONS S YS TEM DETAIL Flaherty Environmental Services P. O . Box 81 1, ALL PRECAST COMPONENTS TO BE H-1 0 Yarmouth Port, MA 02675 RATED, ALL COMPONENTS WITH ANY NUMBER OFACTUAL BEDROOMS 3 774.994. 1166 ANTICIPATED VEHICULAR TRAFFIC TO BE H-20 RATED. GARBAGE DISPOSAL UNIT NO 2. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OFA GARBAGE TOTAL ES TIMA TED FLOW GRINDER. (I 10 GA LIBRIDA Y X 3 BR) 330 GAL./DAY 3. MUNICIPAL WATER IS AVAILABLE. REQUIRED SEPTIC TANK CAPACITY 660 GAL. 4. ALL CONSTRUCTION TO CONFORM WITH 310 CMR 15.000 AND ALL OTHER SIZE OF SEPTIC TANK 1000 GAL. (EXISTING) APPLICABLE LOCAL, STATE AND FEDERAL CODES AND REGULATIONS. SOIL CLASSIFICATION 5. INSTALLERICONTRACTOR TO REVIEW& VERIFY ALL ELEVATIONS AND DETAILS DESIGN PERCOLATION RATE <2 MIN./INCH AND REPORT ANY DISCREPANCIES TO O O 12.83' DESIGNER PRIOR TO CONSTRUCTION OR EFFLUENT LOADING RATE 0.74 GAL./DAY/FTC ASSUME ALL RESPONSIBILITY. LEACHING AREA 6. INSTALLER/CONTRACTOR IS RESPONSIBLE FOR MAINTAINING SAFE (2)x(25'+ 12.83)(2) = 151 SF 25'x 12.83' =321 SF WORK AREA, VERIFYING ALL UTILITIES 472 SFx 0.74 =349 GPD AND NOTIFYING "DIG SAFE" 25' - (1-888-344-7233) 72 HOURS PRIOR TO USE(2)500 GALLON H-20 CHAMBERS WITH 4'STOIVE CONSTRUCTION, AS DIA GRAMMED IN A 12.83'X 25.O'X 2'CONFIGURA TION 7, ANY CHANGES TO OR DEVIATIONS FROM THIS PLAN MUST BE APPROVED IN RESERVE LEACHING CAPACITY NIA WRITING BY FLAHERTY ENVIRONMENTAL SERVICES AND LOCAL BOARD OF HEALTH. 8. FINISH COVER OVER COMPONENTS IS NOT TO EXCEED XPER 310 CMR 15.000 UNLESS SHOWN PER PLAN. (NTS) 9. ALL ABANDONED SEPTIC SYSTEM COMPONENTS TO BE PUMPED DRY AND FILLED WITH CLEAN SAND OR REMOVED SOIL EVALUATION ' AND REPLACED WITH CLEAN SAND. 0F1w TESTHOLE#1 F#1052 TESTHOLE#2 P#15552 gss 10.ALL COMPONENTS TO BE PROVIDED Evaluator., David D.Flaherty Jr.,RS,REHS Evaluator., David D.Flaherty Jr.,RS,REHS DAV WITH WATERTIGHT ACCESS PORTS SE#2755 SE#2755 D BOH Witness: Don Desmarais,RS BOH Witness Don Desmarais,RS WITHIN 6"OF FINISH GRADE, FLA Date: December 13,2017 Date. December 13,2017 11.ALL SEPTIC TANKS, DISTRIBUTION 11 BOXES AND PIPING TO BE INSTALLED TH-I ELEV.58.0' TH-1 ELEV.58.0' WATERTIGHT, 12.NO KNOWN WETLANDS OR WELLS 0--4- A LS IOYR212 kN 0--4- A LS IOYR212 SgNrra WITHIN 100 FEET OF PROPOSED (q LEACHING. 4--20" 8 LS I0YR516 til 4'-20- B LS I0YR516 13.THIS IS NOT A CERTIFIED PLOT PLAN AND UNDER NO CIRCUMSTANCES IS THIS PLAN TO BE USED FOR ZONING OR BUILDING PURPOSES, certify that on November 12,2002,l have passed SITE AND SEWAGE PLAN 14.LOT IS SHOWN AS ASSESSOR'S 20"-126" C2 MS 2.5Y616 PERC 20"-120" C2 MS 2.5Y616 the examination approved by the Department of PROPERTY MAP 175 PARCEL 25, Environmental Protection and that the above analysis FOR as been performed by me consistant with the 15.LOCUS PROPERTY IS NOT LOCATED h B & B EXCAVATION, INC. required training,expertise,and experience described WITHIN AN AQUIFER PROTECTION in 310 CMR 15.018(2). ALAIN ROUSSEAU G.W ELEV.NIA G.W ELEV.NIA DISTRICT(ZONE II). 68 MORGAN WAY BOTTOM TH-1 ELEV. 47.5'. BOTTOM,TH-2ELEV. 48.0', WEST BARNSTABLE, MA PAGE20F2 ................................................... .................................................... ......................-........... ........................................................................................................................ ...................... ............................... ................. ...... ... ......... ... . ... . ........ .. ........ ................................ ....................................................... ........................................ ............ ........... ......................................... , d w ) rx „ Al '.•:i`' - -5 p s ... ,..."....... ,a :."._., , ...... ..,.. .. r" ... , ,::_- , t S. _.. -.., ..-. , _,! . _ .. .k '.'y.» J is .t:;-' #r -,�... :S• )" �1 T < ( 2..,TEST __PIT _ TES. T_# , . . � _ ERA , l0- �- GEN L NOTES _ELEV. . � .., ! ELE 3 I2 � , Q ` 7. I* T TOPSOIL f , . TOPSOIL ; P IL _ 1. ALL ELEVATIONS SHOWN ARE BASED "UPON N w. . I . SU OIL BS . Z `ASSUMED BASE SUBSOIL t . , ME SOME r� �i k r I_ o i 2. P TCH ALL LINES A MIN M M , CLAY , - -. r. ..r ; MINI MU OF 1!8 /FT, UNLESS A z , CLAY 5 - _ OTHERWISE SPECIFIED. " ._ 000000 0 ® © OOOOod CLEAN , o . 0 3 s 7 MEDIUM ,._�, � _ ._� .� ,. _ _ _ _ I _�" _ 00 0 0 O O O ® O O 000 ALL PIPES TO AND IN THE SYSTEM SHALL BE CAST xn s cv o 0 0 0 O ® ® 0`0 0 0 IRON R SCHEDULE 4 �a s AN 5 � T o o � d _ o LE 0 PVC.. �j CLEAN SAND _ l C GRAVEL -t-. _ 00 0 0 m{� ® 00000,0 r MEDIUM. A o _1 4. ALL SEPTIC TANKS, .DISTRIBUTION BOXES AND ..n MEDIUM O I 000 0 0 0 iL��O 0 0 0 00 5ANDo "� _� 0 LEACHING PITS SHALL BE DESIGNED FOR H-20 WHEEL a TO 00 0 O 0 ® © ID 0 0 0 0 00 LOADINGS WHEN UNDER PAVING. f , GRAVEL ( _ LARGE 000 0 0 0 m ® O m 0 0 000 MEDIUM CLEAN 90 14 000000 ® ® ® 000000 5. REMOVE ALL UNSUITABLE MATERIAL BENEATH` THE TO LARGE 3(.0 cn000000 ® O O 000000 INVERT ELEVATIONS OF THE LEACHING PIT FOR--`. -' = 5T0�'=� MEDIUM -�SAND 40 TYPICAL DISTRIBUTION BOX 00 0 0 0 Cg 0 0 0 0 0 000 A DISTANCE' OF 1OFT. AND BACKFILL WITH CLAY- , r ED/LARGE LIQUID LEVEL = FREE SAND ,a GRAVEL HAVING A .PERCOLATION RATE` STONE NOT TO SCALE 61_0ir OF 2 MINUTES PER INCH OR LESS. 18 r NOTE- DISTRIBUTION BOX AND t5.0.0. 6. THETOWN OF BARNSTABLEBOARD OF HEALTH MUST I -NO WATER ENCOUNTERED GAL. REINFORCED SEPTIC TANK BY BE NOTIFIED WHEN THE SYSTEM IS NEAR COMPLETION j AND PRIOR TO BACKFILLING. OBSERVATION PIT TYPICAL 1500 GAL. SEPTIC TANK ACME PRECAST OR EQUAL. TYPICAL LEACHING PIT ` - 7. UNLESS OTHERWISE NOTED, ALL.SYSTEM COMPONENTS PERCOLATION RATE a<2 MIN/INCH NOT TO SCALE NOT TO SCALE SHALL BE INSTALLED IN ACCORDANCE WITH TITLE OBSERVATIONS BY' GERALD DUNNING NOTE- TANKS REINFORCED THROUGHOUT WITH OF THE STATE SANITARY CODE AND ANY LOCAL TOWN OF BARNSTABLEBOARD OF HEALTH ELECTRIC WELDED WIRE WITH 24-1/2 RULES ` WHICH MAY APPLY. 11. OBSERVATION PIT TO BE EXCAVATED TO 4' ENGINEER: ARO ENGINEERING INC. EMBEDDED STEEL RODS IN TOP a BOT BELOW THE PROPOSED BOTTOM OF PIT 8• CONTRACTOR IS TO NOTIFY ENGINEER, PRIOR TO THE DATE: AUGUST4.1994 TOM. CONCRETE IS 4,000 PS.i. TEST. ELEVATION TO VE RIFY SOIL CONDITIONS INSTALLATION of SEPTIC SYSTEM, OF ANY'DISCREP- P 8255 AND WATER TABLE. ENGINEER TO BE ANCIES BETWEEN TEST PIT RESULTS AN6 FIELD' NOTIFIED OF ANY VARIATIONS PRIOR TO CONDITIONS. THE START OF CONSTRUCTION,. 9. ACCESS MANHOLES To SEPTIC TANKS AND LEACHIING ` PITS TO BE .BUILT UP TO 12 INCHES BELOW FINIISH GRADE. 10. NORTH ARROW IS NOT TO BE USED FOR SOLAR PUIRPOSES ` TOP OF „.. FOUNDATION ELEV. 9*50 FINISH GRADE FINISH GRADE' ` FINISH GRADE OVER LEACHING FINISH GRADE OVER TANK OVER "D�� 60X AREA ELEV = 37+4 8 37+2 y ELEV.= 37«5 ELEV.= 35+5 ELEV. 378 EXIST. GROUND 7 Y INV.- 354+5Q= -=_ _ .. ,.: V��aSHLD S i ONE ZQ' a --- I Ntil 32 INV .f,. T 1658I_sf s.� INV.- 33#25 1500 GAL. iNV.�3 -104 v .... .......... r--: DIST. BOX "I b se.2� REINFORCED �' ..... 24��x 3/4itx '1 �2 a11 GUNCRETE % (TO BE LEVEL a .L• / LOT 15 9 0 �..,� WASHED S' .:::7.I. ::: a TONE r .. p0 z w �'"� \ � & STABLE) �l R39.22 6ti SEPTIC TANK `BO 0 OF T t (TO BE LEVEL & STABLE) INV.= 27a00 ELEV. 3+100 ' g t \3s,®2 I 6 �,_ ' . _TYPi CAL SEWAGE SYSTEM PROR LE PRI=CAST LEACHING PIT :.• 3 .s s . A �. ., (T0 BE LEVEL & STABLE) t" PR o+os r NOT TO SCAL E , z � LEGEND 41 _ \ 33.e2 MAP ECTI N PARCEL LOT ADDRESS t' $ ''; �• s��krHc �. �• ,^� P EXIST. CONTOUR 6 �-— — — — 175 25 159 #68 , PROPOSED CONTOUR 8� ! ' EXIST. SPOT ELEVATION 8 X O PROPOSED SPOT ELEVATION 8♦0 ,�,, e� ,r / ZONING DISTRICT, FLOOD HAZARD ZONE , ? �.. PERCOLATION TEST _ , RF :, C OBSERVATION PIT 1 • I : " R�„ 1 as - IVIL OD �. . , w PROPOSED LOCATION OF DWELLING DESIGN CRITERIA - - s .. P L( 00 N & SEWAGE -DISPOSAL SYSTEM ` R � t?0 ENCH MARK, 4r f R ,,- NUMBER BEDROOMS. ��� IN op of Hydrnnc spar► 1 ., w; 2 PERSON PER BEDROOM : .,,f: ; ' -� + -1 ` I + ----- - F�t: 3 P _ e� .� 55 N : _ LET 159t # 68) MORGAN WAS ------� �z GALLONS PER_PERSON PER DAY ., eRO, - ` LEACHING REQUIRED 440 qPd W BARNSTABLE MA . , LEACHING PROVIDED apd MORGAfiJ t f DISPOSAL , _ 1 .: . .A #. , APPLICANT ENGINE ER ` . w4Y � .. , 4. 1 .Kr,1INC.`s , l%�t . THE IRENE TRUST ARO ENGINEERING IN I. ti SEWER DESIGN -� a'" 39 STRIPER LANE P.O.BOX 599 . , ..,. _, ALMOUTH A. 02536 S MASHPEE, E. F , M p t W 2tt�x 4 x 2.5 x.6 Jr 37717 d MA. 02649. SIDE ALL 9> ,- t n x 4 x i , .;.., SGdI.E DATE SHEET BOTTOM .o so.i 9Pa <,s -�€! 15 0 9C 60 - 9ti " � ' " ,� AS SHOWN, AUGUST 4, (994 1 OF 1 ;- TOTAL: 427.3 � x 9 = 854.6'gpd �, �J y. ; DRAWN BY= CHECKED BY APPD. BY PLAN NO. ' = SCALE IN -FEET � _ PLAN SCALE 1 r CP/HP R -RER ... [ D. AU REVISED. 10, 1994: RELOCATE GARAGE & SEWERAGE: PER , .v r. _. .wBFr• .' ax' r:>. .- ,:,.. _,_ _ _. .. ., . +.. .:, a. [. s_ ... _ -..,-,. , ... mr ,3i , .._- _. .. , _ ,,,..,.: ,.. _.....'.b�'.,.c _r:-, ., .s+++.t-A.:,._,o `�� -. .. .,•, r-., .Siy ,. ... .. 71. . +R...w+ .,. r. .n- .,.- x, .::. ... -,.7 , ... ,. ..._„... .. -