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Home My WebLink About0071 MORGAN WAY - Health 71 MORGAN WAY, W. BARNSTABLE A=174-1-66 o � „ a R � v o e 1 � o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 71 Morgan Way Property Address Finch/Thomas Owner information Owners Name I" is required for West Barnstable MA 02668 11/8/17 � every page. F: 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. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r 11/8/17 lnspec6eg 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 O eva r-- Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 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.doc•rev.6/16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way Property Address Finchl'Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 CityrFown 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 El ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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.doc-rev.6/16 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 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 Cityrrown State Zip Code, Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ( 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 CitylTown 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: Pumped April 2017 per owner 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1998 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Inlet and outlet covers raised to 6"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: trace t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 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 >12 11 Scum thickness trace Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" 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.): Pumping suggested every 3 years to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No adverse conditions observed Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): offDepth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is 3' below grade, carry over in box, box cleaned at the time of inspection Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *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: I t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers are 3' below grade, cover raised to 6"of grade, pert pipe runs thru chambers end to end, there was 9"of effluent in chamber at the time of inspection, no indication of past fail conditions Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Morgan Way Property Address FinchlThomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Soils are compact and dry Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Morgan Way Property Address Finch(Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8/17 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 0 5-C) `� t t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for West Barnstable MA 02668 11/8/17 .every 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: >20'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: Per 1998 compliance seperation to GW is met ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 ._ I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way Property Address Finch/Thomas Owner information Owner's Name is required for every page. West Barnstable MA 02668 11/8117 Cityrrown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION M012jaf1 S1 wnl?# ►�Sd� VILLAGE LV `�.(V\Snl bU ASSESSOR'S MAP&PARCEL IKffA+, S NAME&PHONE NO SEPTIC TANK CAPACITY n LEACHING FACILITY:(type) Ctinnh� (size) �()C> �,c�' NO.OF BEDROOMS 3 OWNER f'V wk PERMIT DATE: ATl Pn W I'O I7, I1 b 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 ands exist within 300 feet of leaching facility) Feet FURNISHED BY YMC) 4 ♦ t \ 4 4 4 \ \ \ 4 4 4 ♦ \ ♦ 4 4 4 4 4 4 4 4 t ♦ t t \ \ \ \ ♦ \ \ f f f / f J f f f / f f J J f f f f J f f f f f f f f f f f f 4 t \ \ \ 4 \ 4 \ \ \ t 4 4 4 t \ \ t \ \ \ \ \ \ \ \ \ \ \ \ t \ \ 4 f J f f f / f / J f f ! f f J J f l f f f f F 4 \ \ 4 4 4 \ 4 ♦ \ ♦ 4 ♦ ♦ 4 4 \ 4 4 \ \ 4 t 4 \ t \ t ♦ f 4 \ 4 t t t t \ ♦ \ ♦ t t t \ t ♦ t \ t t t ,aJ\J♦ ! ♦ \ t 4 4 4 4 4 4 \ 4 \ \ \ \ 4 4 4 4 4 4 4 4 4 4 4 4 4 4.4 4 4 4 \ \ \ \ \ 4 4 ♦ 4 \ \ 4 4 4 \ 4 \ \ \ t ♦ \ 4 \ ♦ \ ♦ \ ♦ t t \ ♦ \ \ \ 46 35 - 37 56 " ~ T •? Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way Property Address Ernest Incorvati — Owner Owner's Name information is West Barnstable MA 02668 August 3, 2010 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: (� only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name 189 Cammett Road — Company Address Marstons Mllls MA 02648 _T_' City/Town State Zip Code 4 O 508.428.1779 S112855 _ Telephone Number License Number B. Certification '' -f I certify that I have personally inspected the sewage disposal system at this address and that die information reported below is true, accurate and complete as of the time of the inspection. The-in Action was performed based on my training and experience in the proper function and maintenancef ohite sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 16.000). The system: a ® Passes ❑ Conditionally Passes ❑ Fails f ❑ Needs Further Evaluation by the-Local Approving Authority l _ it August 3 2010 Job# 10-197 _ l spector's ign� 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. [A ' Title 5 Official Inspection Form:Subsurface Sewage Dispos4.m•Page of t5ins•09/08 p Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 71 Morgan Way — Property Address Ernest Incorvati — Owner Owner's Name information is required for West Barnstable MA 02668 August 3, 2010 every page. Cityfrown 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: Tank was scheduled for pumping following inspection. Leaching system shows no signs of hydraulic failure or surcharge 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): l5ins•09/01 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way — Property Address Ernest Incorvati Owner Owner's Name information is west Barnstable MA 02668 August 3, 2010 required for — every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed 0 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 16.303(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-09108 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 71 Morgan Way — Property Address Ernest Incorvati — Owner Owner's Name information is West Barnstable MA 02668 August 3, 2010 — required for State Zip Code Date of Inspection every page. CitylTown B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: — **This system passes if the well water analysis, performed at a,DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow l5ins-09108 Title 5 Official Inspection Four:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way — Property Address Ernest Incorvati — Owner Owner's Name information is required for West Barnstable MA 02668 August 3, 2010 every page. Cityrrown 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. [Thus system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 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-008 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way _ Property Address Ernest Incorvati _ Owner Owner's Name information is West Barnstable MA 02668 August 3 2010 required for 9 _ every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 — ti t5ins•og/o6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way _ Property Address Ernest Incorvati _ Owner Owner's Name information is bl t t Ba rnstable MA 02668 August 3, 2010 required for W g — every page. City[Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): N/A irrigation system. _ Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. — Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow(based on 310 CM 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•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Mas sachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way _ Property Address Ernest Incorvati _ Owner Owner's Name information is West Barnstable MA 02668 August 3 2010 required for 9 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped 8/2/06 — Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: — Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract. ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Morgan Way _ Property Address Ernest Incorvati _ Owner Owner's Name information is �West Barnstable MA 02668 August 3 2010 required for 9 — every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Compliance date: 6/29/98 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): . 3, Depth below grade: feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): — Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): _ Depth below grade: 2'feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5' long x 5.8'wide- 1500 gal. 2° — Sludge depth: — l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 71 Morgan Way _ Property Address Ernest Incorvati _ Owner Owner's Name information is MA 02668 A bl t t Ba rnstable August 3, 2010 required for W g — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" — 1" Scum thickness — Distance from top of scum to top of outlet tee or baffle 6" — Distance from bottom of scum to bottom of outlet tee or baffle 13" — How were dimensions determined? Measured — Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert and tees were intact. Tank was scheduled for pumping following inspection. — Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: — Scum thickness — Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping: Date t5ins•091138 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way _ Property Address Ernest Incorvati _ Owner Owner's Name information is West Barnstable MA 02668 August 3, 2010 _ required for 9 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: — Capacity: gallons .Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date — Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way _ Property Address Ernest Incorvati _ Owner Owner's Name information is West Barnstable MA 02668 August 3 2010 required for 9 every page. City[rown 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 Oil - 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.): No solids or high stains. Liquid level was found at bottom of outlet pipe. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way Property Address Ernest Incorvati Owner Owner's Name information is West Barnstable MA 02668 August 3 2010 required for W 9 — every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: — ® leaching chambers number: Two 500 gal drywells. ❑ 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.): Area of SAS was probed and no signs of saturation were found. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth—top of liquid to inlet invert — Depth of solids layer — Depth of scum layer — Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �r 71 Morgan Way Property Address Ernest Incorvati Owner Owner's Name information is West Barnstable MA 02668 August 3, 2010 _required for g every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — Dimensions Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f _ Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 71 Morgan Way Property Address Ernest Incorvati Owner Owner's Name information is required for West Barnstable MA 02668 August 3,2010 every page. Cftyfrown 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 _ _. r r r r r'r`r`r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r rrrr i r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r \r\r\�r\r\r\r\r\r\ \ \ \ \ • r\r\r\r\i r\r\i r r�i r\r�r\i r�i r�r\r\ rrrr r r r r r r r r r r r r r r r i r{ \ \ \ \ r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r �r�i r�rtr�rti iir\r\i r\r 46 37 35 56 a Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way Property Address Ernest Incorvati Owner Owner's Name information is West Barnstable MA 02668 August 3, 2010 required for g every 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: 20+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: Perc test performed prior to construction found no water at 12 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Morgan Way Property Address Ernest Incorvati Owner Owner's Name information is West Barnstable required for MA 02668 August 3, 2010 every page. Citylrown 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•0908 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 =r \ COMMONWEALTH OF NIASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS t DEPARTMPITT OF ENVIRONMENTAL hROTE'CTION TITLE 5 OFFICIAL INSPECTION FOR 4—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWA.GE-DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: J �7 ,�L / Owner's Name ! e.. Wit. ✓ Owner's address: �.; C% 00 Date of inspection`: `�,, , f C 0 ,�j r Name of Inspector•(pleas p' int) k 5 '�; i / ,1�' Com an Name:C 7 _ _ p; Y r Mailing Address: A: . ' 1 ) A L-In4 A Telephone Number; CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and`that the information reported below is true,accurate and complete as of.the time of the inspection.The inspection was performed based on my training and experience.in the proper function and maintenance of on site sewage disposal systems.I am a.DEP approved system inspector'pursuant to Section 15.340 of Title 5.(310 CMR. 15.900) ,The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approv:ina Authority Fails I M, Inspector's Sigllature: Date: The system inspector shall- submit a copy of this inspection report to the Approving Authority(Board of Health or`W DEP)within'DO days of completing.this i .inspection.If the system is, shared system or has a desgn flow ofJ 0;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;Y autho.rity. .-- Notes and Comments This report only describes conditions at the time of Inspection and under,the conditions.of use at that time.,This inspection does not address'how the system will perform in thefuture under the same or different - conditions of user Title:5 Inspection Form 16/15/2000 page .1 Page 2 of 11 OFFICIAL INS.PECTIO:N FORM-NOT FOR VOI:UNI'ARY ASSESSMENTS SUBSURFACE SEWAGE'.DISPOSAL SYSTEM.INSPECTION FORM PART.A CERTIFICATION (continued) Property Address. l � �. 6 D ' Owner Date of Inspect Son InspectionSummary:.Check A,B,C,D or E.I ALWAYS complete.all of Section.D A. vstem Passes: I have not found any information which.indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CNIR 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 nee&to be replaced or repaired.The system, upon completion of the replacement or repair;.as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND):in the for the following statements. If"not determined"pease explain. The septic tank is metal'and over 2.0 years.old, or the septic tank(whether metal or not)is structurally unsound, exhibits substantial:infiltration or exfiltratiori 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: . ND explain: Observation of sewage.:backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with. approval of Board-of Health), broken pipe(s)are replaced. obstruction is-removed distribution.box:is leveled or replaced ND explain: The system required pumping more than.4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the.Board of Health): broken pipe(s),are replaced obstruction,is removed ND explain: Paee of 11 OFFICIAL INSPECTION:FORM - T RM .NOT FOR VOLUNTARY: SUBSURFACE SEWAGE.DISPOSAL SYSTEMINSPECTIOMFORM PART:A CERTIFICATION(continued) Property Address:./ C 'i✓1Z Owner: Date of'Inspection: s r _ C. Further.Evaluation is Required by.the Board.of Health:.: Conditions exist which require further evaluation bythe..8oard 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 protlect 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 sali'marsh 2. System will fail unless the Board of Health (and Public.,Water Supplier, if any determines that the system is functioning in a manner that protects the public health,safety.and environment: The system has a septic tank and soil absorption system (SAS)and the SAS'is.within 100'feet of a. surface water supply or tributary-to a surface water:supply: The system has a septic tank and SAS and the SAS is within Zone l 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 l00 feet.but'50 feet or more-from a private water supply:well`*. Method used to determine:distance "This system passes if the well water analysis;performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided thatno other failure criteria are triaeered. A copy of the analysis must be attached to this form:. 3. Other: I 3. Page a of l l OFFICIAL INSPECTION FORM..'—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION.FORM PART'A. CERTIFICATION(continued) Property. ddress: Owner: z Date of Inspection: O(a D.. System Failure. -riteria 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 ondin of effluent to the surface g 's rf ce of ound.or surface waters due— — _ P g cr to an overloaded or clogged SAS or cesspool Static liquid leveltin the distribution box above.outlet.invert due to an:overloaded or.clogged SAS or / cesspool Yl Liquidl depth.in cesspool is:less.than 6"below invert or available volume is less than %day flow Required pumping more.than 4'times in.the last year NOT due to clogged or obstructed pipe(s).Number of times Pum ed P _ Any portion of the,SAS,cesspool or privy is..below high ground water elevation. Anyportiori 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 1.00 feet but greater.than.50 feet.from a private water supply well with no acceptable.water quality analysis:.[This system passes if.the well water analysis, performed at:.a DEP certified,laboratory,for coliform bacteria a d v- a i a P ry., n of the orbaniccompounds indicates that the.well is free from pollution from thaf:facility'and the:presence of ammonia nitrogen.and;nitrate nitrogen.is equal. or less than 5 ppm, provided:that no,other failure criteria , are triggered..A copy of the analysis.must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure:criteria exist as described in 310 CR 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 larger'system the system must serve a,facility.-with a design flow of 10,000 gpd to 15,000 gPd You must indicate either"yes" or"no"to each of the following; (The followingg criteria apply to large systems.in addition.to the criteria above) yes no the s stem.is within 400 feet a.surface drinking water supply _ Y . P:ly _ — the system is within 2.00.feet.of a tributary to a surface drinking water supply stern the s i c — _ system s located in a nitrogen sensitive area(Interim Wellhead Protection Area.—IWPA) or a mapped Zone Il 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 abo.ve 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. Paae 5 of I OFFICIAL.INSPECTION.FORM—NOT'FOR VOLUNTARY ASSESSMENTS SUPSURFACE'SE ✓AE DISPOSAL SYSTEM INSPECTION FORM :PARTS CHECKLhST Property Address: 2L� Owner: ..�' �: ° .- `�..� ,('�f~.('��,�=�<,,,✓ Dateof1nspecfio-n:-Sz,,j , )(" 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 larcre volumes of water been introduced to the system recently or as.part of this inspection? �� II Were as built plans of the system obtained and examined? (If they were not available noteas N/A) —/_ Was the facility or dwelling inspected for signs of sewage backup .. Was the site inspected for si&ns of break out? r 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 sludgel,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`determine`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)] Page 6 of l l OFFICIAL INSPECTION:FORM I'+1.OT.FOR:V1. OLUNTARY ASSESSMENTS . SUBSURFACE:SEWAGE DISPOSAL SYSTEM[ INSPECTION FORM PART.C SYSTEM INF.ORMATIOi`d Property Address: Owner: Date:of Inspection: . ® - w - FLOW CONDITIONS RESIDENTIAL ` Number of bedrooms(design) .0.� Number of bedrooms(actual).: DESIGN flow based on:3.10 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): 330 Number.of current residents:. . Does residence have a garbage grinder(yes or no): Is laundry on a;separate:sewage system ( es or no):fQ.[if yes separate inspection required] Laundry system inspected(ye..or no):��f� Seasonal use: (yes or Water,meter readings, if av ilable(last 2 years usage.(gpd)):. Q Sump pump(yes or no): _ e. r Last date of occupancy::( j: 1 C, /l-� ,/ GA��e�� 1 vk COMMERCIALIIND•USTRIAL/ Type of establishment.: Design flow(based on 310 CMR 15.203): gpd .Basis of design flow(seats/persons/sgft,etc,): Grease trap present(yes:or no);._ Industrial.waste holding tank present(yes or.no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records / T Source of information: .A/O ALumk(1)f Was system pumpedas part of he inspection(yes, no): 1 0 t' If yes,volume puinped: gallons--How was quantity pumped determined? Reason for pumping`. T RE OF SYSTEM Septic Tank, distribution box,soil absorption system -Single cesspool Overflow cesspool 's _Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) _Tight tank: Attach a copy of the.DEP approval Other(describe): p roximate age of all components, date ins-al ed(if known) and source of info ation: _ 9e Were sewage odors:detected when arrivin at the site' . es or no (y ) IVIO • 6 Page 7 of I OFFFCIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL`SYSTEM INSPECTIION FORM PART C SYSTEM-INFORMATION(continued) Property Aodress: z j y Owner•l ' / v i,,�C' hl 0 y, t Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC_other(explain): Distance from private water,supply well or,suction line: Comments(on condition`of joints; venting;evidence of leakage, etc.): SEPTIC TANK:(locate on site plan) Depth below grade:. �.o) Material of construction: j concrete.: metal_fiberglass Polyethylene _other(explain) If tank is metal list age:._ :Is a6e.confuzned by a Certificate of .Compliance(yes or no):_(attach.a copy of certificate) Dimensions: Sludge depth: ('] > // Distance from top of sludge to bottom of outlet tee or.baffle:. Scum thickness: Distance from top of scum to top of outlet tee or baffle`. Distance from bottom of scum to botto, of outlet tee or baffle: Q ; How were dimensions.deterriined: L`� Comments (on pumping reco. mmencktions, irAet and outlet tee or baffle condition, structural integrity,liquid levels as.related to outlet invert evidep ce of leakage,etc.): �'.��- } GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: concrete_metal fiberglass Polyethylene_other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom'of scum to bottom of outlet tee orbaffle: Date of last_pumping: Comments (or pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,.): Page 8 of I OFFICIAL-INSPECTION. FORM—NOT FOR YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property, ` dcress: A&A-1 s� -, Owner`� s Date of speciion: ® — t �® T or HOLDING TANK: -tank must be pumped at time of ins ection locate.on site plan) TIGHT /h ( P P P )( P ). Depth below grade: a Material of construction F .concrete metal fiberglass Polyethylene other(explain);. Dimensionsf . Capacity: gallons . Design Flow: gallons/day Alarm present.(yes or no) . Alarm level: Alarm in working order(yes'or no): Date of last pumping: Comments(condition of alarm and:float switches,etc.): DISTRIBUTION.BOX ' (if present must.be opened)(locate on site.plan) Depth of liquid level above outlet invert: r� , . Comments(note;if box islevel;and distribution to outlets equal;.an.y evidence of solids.carryover;any evidence of ,Ieokage into or out of box,ete.): ,. �/ `� %(tea t/ � ,�, ✓ -/,� � j'i1 ; „.'# r. A PUMP CHAMBER% .(locate on site plan): Pumps in working:order(yes or no): t Alarms in workip"..order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 3 Page 9 of 1 1 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM ' :'PART'C SYSTEM,INFORMATION(continued) Property Address: Owner:(A In Date of Inspection: 1--: a , OS2- (0 SOIL.ABSORPTION SYSTEM (SAS): --tz(locate on site plan, excavation not required). If SAS not located explain why: Type leaching.pits, number: _ 7leaching 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) A�o"tlbiz .� 1.., C , 1XI a m . ei � - I. � an 11 ti"p Cat% ✓y r� � � ''r �L'e''(, CESSPOOLS:] (cesspool must be pumped as part of inspec ion)(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 or no): . Comments (note condition of soil; signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids:. Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 9 Paae 10 of 1.1,. OFFICIAL IiVSPECTION FORM .N.OT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F.ORYI PART C., SYSTEM"INFORMATION(continued) Property A :dress: jj 1CAZA&11A---1 &tUA Ali oaq Owner Date of Inspection:. ;L /, __ :*1 6(0 f 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. cy - 7 J (J rtCi (to l'L£ ry) Page 1] of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM PART C SYSTEM INFORMATION(continued) Property ..ddress:;M ,L��,1 Owner: ,. Date of Inspection: "> J SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water �-'t3 feet ~ Please indicate(check) all methods used to determine the high.ground water elevation: Obtained from system design plans on record -If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) _sr Accessed TJSGS database-explain: You must describe how you established the high groundwater elevation: ` G� 11 Permit Number: Date: Completed Iby: :HIGH GROUND-WATER LEVEL COMPUTATION Site Location: e✓ 4M'l w,Ayf'--14 Lot No. Owner: / Address: ,... ..._...:::_,..-........ _ Contractor: ( Address: L//7 Notes: - ----- STEP 1 Measure depth to water table � l to nearest 1/10 ft. ....................................................... ................:... .Date 7l month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map-locate site and determine .Appropn*ate zindex vveII ...... i �.J. Water level range zone ................................................ STEP 3 Using monthly report 'Current Water Resources Conditions c m eterine current depth;to `water level for ...:.......... * i month/Year STEP .4 Using Table;.of;Water-level-Adjustments for index well.:(STEP'2A) :current-depth `to water-level for index--vvell-(STEP 3), and water level zone (STEP 2B) determine water-level:adjustment .........................:........................:....................................... Ft STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water Z�S level at site(STEP 1) ............................:..:......................................:..:...::........:......i.:............ Figure 13.7Reproducible computation form. 15 Mo Re, wiv. "Olt- :L TOWN OF BARNSTABLE LOCATION 14-r L,)�4 SEWAGE # VILLAGE MCS'( eke ASSESSOR'S MAP & LOT ? do •d b INSTALLER'S NAME&PHONE NO. ,I CC.O 4128^ 3085— SEPTIC TANK CAPACITY 1 SOO Sn'AL LEACHING FACILITY: (type)�Z�Spa' C Ch,4ndtrK (size) 12 X 2- NO. OF BEDROOMS 3 BUILDER OR OWNER �SICU `&adArg PERMITDATE: 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 ;3 � b I R o 2 O 3 67 V6 3y � ySS— 7TOWN OF BARNSTABLE LOCATION r06 r2G An w 9-i/- "il. SE 'WAGE # VILLAGE &&&T S+fAeU ASSESSOR'S MAP& LOT 7 . da'-c9 .b INSTALLER'S NAME&PHONE NO.s7)2CQ, . 28- — SEPTIC TANK CAPACITY 1 HOC) LEACHING FACILITY: (type)UZ 6 O 9AL (size) I Z X 2 9'-- . NO.OF BEDROOMS 3 BUILDER OR OWNER I�Slc�.2 �wa°�r� PERMI TDATE: — i g2�COMPLIANCE DATE: 4�; >t<rSeparation 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 p. 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 r `J t03 y ys y4( SP 57b 3S- 3,5 b / F .......10..7?........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Bi_npuuttl VorkB Tunitrurtiun remit Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at . 1.... .c_--.--�;5 � .....�_.__r�.C .......................................... .._. o i 1Add, r Lot No. er vn Address aW C --------- ... ........... o.... Installer Address d Type g Sq. feet T e of Building Size Lot---- �_._�__ 4 Dwelling—No. of Bedrooms._.. _. ....._..._....__.__-Expansion Attic ( ) Garbage Grinder ( ) 44 Other—Type of Buildiug� ham! -No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q, Other fixtures ------------------------------- - - �1- --------- •------ W Design Flow.................... 1 ---------------gallons per pe per day. Total daily flow_.........!_..Z. .......................gallons. WSeptic Tank—Liquid capacitvL.7 gallons Length--_.._:-----_- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Vidth.................... Total Length.......-_--._ ----. Total leaching area....................sq. ft. Seepage Pit No..._....-..-_------ Diameter.--_-------------- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing to�kn( ) Percolation Test Results Performed by.------.�./L. . `7 w.N--------------------------- Date....�� 4,V 1-- 7 a G Test Pit No. 1.....el- ..-..minutes per inch Depth of Test Pit................._ Depth to ground water........-/Q fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit........--_--_--_--. Depth to ground water.........--............. Wn ---------- 0 Description of Soil.........(1) --- -•= --------------------------------------------------------------------------------------------•-----•--•---•-----------. � f U ---•••-•-••• ----------------••-•---------••---•••••-•----------------------------••-•--•----------••-•-••--•-----------... W UNature of Repairs or Alterations—Answer when applicable...-.................................................................................•-..------- ..--••-••-••---------------------•---•--•••-••--•-•----------------------------•-------------------------------.......------------------------------------------------------------•-•••-----•----.----•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —Th undersi Vbe gned further agrees not to place t e system in operation until a Certificate of Comp ' iss d by the board of health. Signed ...... ............... . . ....�----�-- ---------- Dare Application.Approved By ----------- ... .. ----------------------------- ------------------------------------------- ------ --- feet....:. -' Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------- ...............---- -----................--------------------------...................---...-------..._........._....----------------------------- ---------------------------- ---------------- ........................................ Date Permit No. ....!�.. - � --------------------- Issued .............� .. ....................... . q_ Er^ -5_6 Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE t Appliratiun for Divj-pu!3tt1 Worlai Tonfitrurtiun rautit Application is hereby made for a Permit to Construct pp Y �(V) or,.ltepair ( ) an Individual Sewage Disposal System at: ' _ - /s / Lo 5.t \ddr s's r Lot No. ,... W ",0,�•ner Address t a v ✓ Installer . � � � Address ' UType of Building r Size Lot___1.5._._ �....Sq. feet g— ::Expansion Attic (. ) Garbage Grinder ( ) U Dwelling No. of Bedrooms____ _ -._. a`4 Other—' Type of Buildin C�7�i yp g(,�..,. ._,_...,1_!��-�?�No. of persons_____________________-._._ Showers ( ) Cafeteria ( ) Other fixtures --------------- -------------------- - - -" - -'- .... --------------------------------------------- Design W Flow____________________�40_______�_--__gallons per person per day. Total daily flow...___..._..._____. .......................gallons. WSeptic Tank—Liquid capacitvl_�U_galIons Length---------------- Width---------------- Diameter-----._._,------ Depth................ x Disposal Trench-- No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------..-__------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Oth1v Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b r.__ r..... 1 _..__...... .... Date_ _ aTest Pit No. I_____�-- _._minutes per inch Depth of Test Pit.................... Depth to ground water----------I._.,__ LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....N�---------- 9 --------------------------------2........................................................................................................................... p x Description of Soil.........Z-4 �//k / .............................................. V ....---•...•------•-------•------------•----•--•---------------------------------------•-----------------••-. W r UNature of Repairs or Alterations—Answer when applicable................................................................................................. ----------------------------------------------•--.----- Agreement: The undersigned agrees to,install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation'until a Certificate of Comp"liarrcel� s bee issued by the board of health. - Signed �� .-c- --�., �`'------------------------- --- ...--- // Date .. ............ Application.Approved BY q �. �y ---------------- ------- ---------------...----------------. .... . Cf' Application Disapproved for the ollowing reasons: __................................... .._..---------------------- ......._.._. .............................................................. .. ._..........................._....................._......................------------------------- --------------------------------------- Date Permit No. ........ ��,------` -4" .�.. Issued .............. .-.. _.... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE vlertificate of Compliance—OH f IS IS TO CERTIF,.Y, That the Individual 'ewage�spos 1 System con tructe ( `� ) or Repaired ( ) ------ by has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ._1:�1 ..._.._ �._ ..._. dated _-----��.__-_1. ...�.9. :._...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEID AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... ..............__...--..-f�' r ° 1..`d - ...------------- Inspector ........:., -------------------------- -----------------.._-------------- ----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �iu�uu�tl Turku �uatutrttr#i�.n ��erntit Permission is hereby grante ----- _-. -..---- r__4..• "------1.lr ._Z);41../1-:1 .1")-----•-----------------------------•-- to Construct ( V)� or Repair ( ) an Individual Sewage Disposal System atNo. � t .-----.W,17 / , . -------------•----------------._......._.._.._.....--•--............. Street as shown on the application for Disposal Works Construction Permit Noj�._3�r'.>._ Dated........................................... ...--••--•---••-•••--••-•----••••----------------•-----_._.....--•-----------------•----------••-•------- Board of Health DATE................................................................................ 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STEPHEN 1- ALLYN 0 2dnsp N WILS,01^7' Geis 12 Nn Ik 1; yew Ceox-secmow o I= G9A/V f:- — 46-1 Olp TF-S > 4o 1 IIN FS S�IRSC`IL I Iw •Z oz C. IC�Qp Lsutl CAAAMB R5 L'Z E)2,2 bof( 1. C 4 10 - T of ` �« OF "� G-WE `ISA5c-- Lo�t�� Sduu . �JEI.nPc� F¢oFlt,.� 14` Np �c.A1.br 2 c:0A2it SAIJ) G,za L►- C (1 F1GD FI.OT FLAB I(u GL- 14- i-o,--AT rJo Wdr�� .T Ioi-1 CLNTU�✓Ic LC /W BA21J-s'r. P U`]b3 ATE ,UAL.. I'z I'I"iE' PL6,W ZGFEZE., I CszT1r-`1 Tl-4AT THE Fov��ar�o� 5�4otiuN ►+ oN coMP�-y5 w1T� Tt srt .uN A� T�_. -i�;L Z;GTgA V- 2EaL;jZG�AAGgT OF TWG, TivP4 of AIAT- 1-14 FAQ- l-&L- T-11rL�J�,TAN,cc= ADD lS [ Tr LlX-ATeD WIT1�IN /� N`/M I NG eL TM-LrcpnnHA7�l� ZONE. 5ujzvVC7,5 • QQ INNS 3 I Z fig, ILA G `= /��' oST�evlll�► MASS. oFFSeT^ . VV-oM BVIC.D1h1l� 5►10�� Nor B6. ��uG4NT: '�)p� S IAA D�I�y�►�G C, I�1G L>,,eD Tv r�TA�usy PQopazTy LI�1�S. MAP 1-74 Zoalk)6 30 Z ' ,^ It \ Qj a p�opo li / N ' r / N �DwE�i�,G �CA21 l�o ao