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HomeMy WebLinkAbout0090 PINE STREET - Health 1 ,40 pine,,Street , k •_ ,#Wi Barnstable �I I Commonwealth of Massachusetts . Title 5 Official Inspection Form s - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 April 29 2015 required for every P , page. Chy/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when tilling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor do not David D. Coughanowr, RS use the return Name of Inspector key. Eco- Cohi Tech Rapid Response Company Name 155 George Ryder Road South Company Address " " Chatham MA 02633 C /T n it Y State Zip Code 508 364-0894 1328 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 -,tx 0F hiss Conditionally Passes ❑ Fails Needs Furthe I V , ❑ uatia l� the I Approving Authority U �. Y PP g Y c� CICUCHAN( WR En o. 1093 Aril 29 2015 Inspector's Signature i Date S�tJl TPrytt'. The system inspector sh I t 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. 151ns•3113 T19e Abtflcdialpoction Form:Subsurtaco Sewage 04sposm System-Pago 1 of 17 ?� Commonwealth of Massachusetts .� 4 Title 5 Official Inspection Form f"s'- Subsurface Sewage Disposal System Form- Not for Voluntary Assessments " 90_Pine Street Property Address ` William and Mary Devine Owner information is Owner's Name - West Barnstable MA 02668 A rtl 29 required for every _ ��� , 2015 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 CINR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: �� a ❑ 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): Isms-3/15 Trtlo 5 N16W Inspection Form:Subsunace Somage otsr>nsel System-Paps,2 of t7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dlsposal System Form-Not for Voluntary Assessments :. � 90 Pine Street Property Address William and Mary Devine Owner Owner's Name —� information is �?required for every West Barnstable MA 02668 _A rtl 29,2015 _ page. Cityrrown State Zip Code pate 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 15ins•T13 Title 5 Off oal fnspeckn Forms Subsurface Sewage orsi mal system-page 3 of 17 I� Commonwealth of Massachusetts {3 Title 5 official Inspection Form I° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Pine Street Property Address ' William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 _A ril 29, 2015 . required for every _ ,_____ p page. City/Town State Zip Code Dale 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 ❑ a 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 ❑ Z 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 t5tns•3;t9 Title 5 Official hYspeclion Form:Subsurfaco Sowngo Disposnl Sysle,n•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information ie West Barnstable MA 02668 April 29,_2015 required for every _ page. Cityrfewn +- Stnte Zip Code Oato 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 collform 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.] ❑ g 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 Ej ❑ 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. t51ns•31f 3 Yltle 5 Official Inapaction Form;subsulece Sowatlo Disposal system•page 5 of 17 r E?; Commonwealth of Massachusetts p Title 5 official Inspection Form 0Subsurface Sewage Disposal System Form-Not for Voluntary Assessments R , ..` 90 Pine Street � M Property Address _William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 A nl 29 2015 required for every --•--_ _. p ,_ `.___-- page, City/Town State Zip Code hate 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? Z ❑ 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): n/a— Number of bedrooms (actual): 5 - - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x##of bedrooms): Na no plan 15In 3na T1110 5 Ottidal Iaspectinn Form:Suusuttaco Sawaga Disposal Systorn•1'aUa 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface r.� Sewage Disposal System Form-Not for VoluntaryAssessments x 90 Pine Street Property Address William and Mary Devine Owner Owner's Name_ information is West Barnstable MA 02668 Aril 29,2015 required for every _._.__. P page. Ci(y/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 Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): n/a-well in use Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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: t56is•:03 Title 5 Otlpclal Inspection Form:Subsurlaca Sowape Disposal System•p,,Uc 7 0117 Commonwealth of Massachusetts li r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Pine Street Property Address William and_Mary Devine Owner Owner's Name information is West Barnstable MA 02668 A nl 29 2015 required for every - _ P page. CilyfTown 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 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 s � ❑ P stem P y ❑ 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): Septic Tank and 2 Leach Pits. t5hls-3113 n1lo 5 Official InspectlUn rorul:SulnudnCe Sewage Disposal System-Pa0a it of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Pine Street y Property Addross William and Mary Devine _ Owner Owner's Name a information is West Barnstable MA 02668 Aril 29, 2015 required for every _p page. CdylTown State Zip Code Date of Inspection D. System Information (cont.) . Approximate age of all components,date installed (if known) and source of information: Age unknown—system is assumed to have been installed at time of dwelling's construction in 1972. An overflow leach pit was added in 1987 per-as built card at Health DeptY(permit 87 430). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 _ 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.): Sewer line is behind finished wall and not accessible for inspection. No evidence of leakage or backup into dwelling was observed. ___________ Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 x 5 x 6-1000 gallon Sludge depth: 7 to t5ins•3113 TIIIe 5 Official Inspection Form;Subsurface Se°nstge Disposw Syslf:m•Noe 9 of 17 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �r 90 Pine Street Property Address William and Mary Devine Owner Owner's Name _information is West Barnstable MA 02668 A rti 29,2015 required for every � P 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 ?7 in Scum thickness trace Distance from top of scum to top of outlet tee or baffle 10 in�_ - Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? As built card - �- 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 not required at this time, but maintenance pumping is recommended within 2 years and every 2-4 years thereafter with full time year round occupation.Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: leaf -- 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: oats f5fns•1t3 Tfl;e 5 Official oupecwn Ferro:Subsuffade sowafte o'spesaf system Pit{,Ic to of t., _ Commonwealth of Massachusetts Title 5 Official Inspection Form IS Subsurface Sewage Disposal System Form-Not for Voluntary Assessments } 90 Pine Street Property Address William and_Mary,Devine Owner Owner's Name F —` information is West Barnstable MA 02668 A n required for every p 'l 29, 2015 page. Cityrrown State Zip Code Dato 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 ISina 3it� Tltlo 5 01 icial Innpoclion Form'Subsurlaco Sowgtt Disposal Spstom•Pngo I t n1 17 Commonwealth of Massachusetts .a Title 5 Official Inspection Form + � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '•i.•° 90 Pine Street Property Address "`-- William and Mary Devine Owner Owner's Name - -- --• -___ information is April West Barnstable MA 02668 29, 2015 required for every ..,.. . � page. CitylTovm State Zip Code Date of Inspection D. System Information (cost.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert ------ -- --•- - - ---- --- -- Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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: t91ns•3113 Yttlu 5 0111r.1ui Inspocuun rortll'Subsarfau Suwagu Mapmal Syslurn•Pngo 12 of 17 ct Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 Aril 29, 2015 required for every _ _._. _ _p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: — ❑ overflow cesspool number: --- --- ❑ innovative/alternative system Type/name of technology: w---- �---- --- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching pits appear unsaturated. No evidence of surface ponding, breakout,lush vegetation, or other evidence of hydraulic failure was observed. Overflow pit was uncovered and found to be empty. No staining at cover interface or in overlying:soils was observed. 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 (Sins•3/1 J Title 5 01ficinl Inspection rorrn:SutnuHoco Sowago Disposni systom•Pepe 13 of 17 Commonwealth of Massachusetts - a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Pine Street_ Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 A rll 29 required for every _p_ ¢2015_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc..): Privy(locate on site plan): Materials of construction: — -- Dimensions -- Depth of solids — ------ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):, t5ins-113 Titlo 5 Official Inspoction Form:Subsurfaco Sowago Disposal System•Pago 14 of 17 f fc Commonwealth of Massachusetts - = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 April 29,2015 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 U(3 LEACH FOR MORE INFORMA TION PIT ON SEPTIC SYSTEMS GO TO ECO—TECH.US LEACH 9 PIT THIS SKETCH IS LOCH TONS BEST VIEWED IN COLOR FORMAT —OF SEPTIC COMPONENTS 2 —DISTANCES IN DECIMAL FEET 1000 GALLON A B SEPTIC TANK 1 21.5 33.5 1 2 25 37 3 58.5 54.5 A 8 4 63 75.5 NOT EX§S T dN(G TO SCALE DWELUNG 'I � I 1_�PAVED DRIVEWA Q WELL \_ 508 364-0894 15111•3/13 Tide 5 Olfldal Ins ucNon Farm:p Subsurface Sewage Dtsposnl System Page 15 of 17 r Commonwealth of Massachusetts r ' R Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Pine Street Property Address — William and Mary Devine Owner Owner's Name information is West Barnstable __ _ _ MA 02668 A nl 29, 2o15 required for every _p � _ 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: 25+ —»----- - 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) 11 Checked with local Board of Health - explain: 17 Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: Town of Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater table. Before filing this Inspection Report,please see Report Completeness Checklist on next page. i51na an 3 Tirto 5 c1licial Inspocllon f:onn:Subsorfnco Sewago Disposni Syenem•Pap 16 of 17 Commonwealth of Massachusetts 4. . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 Ar required for every Pil 29,2015 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E3 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 GEOHYDROLOGICAL PROFILE — NOT TO SCALE I I PRECAST LEACH PIT 0 N BOTTOM OF LEACHING PIT LEACHING is ABOVE Ian AT R GROUNDWATER ELEVATION PEA G1 S MAPS 15ms•3/13 Title 5 OtteclN Inspection Form:Subsurface Sewage Disposal System•Page 17 0117 t Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 June 5 2013 required for every , page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your ./ 31f cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Environmental r� Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 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 J June 5 2013 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. ( d I/ZIP t5ins-3/13 Title 5 Official Inspection F bsur ace S Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M Sey`e 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved b i p p Y p p p p pP Y 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. f *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20'years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Spyo 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 June 5 2013 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/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 r r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Pine Street 'M Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 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 Y2 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 ;M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-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 ° 90 Pine Street �M Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 page. 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): n/a Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a-no plan t5ins-3113 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 °M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 June 5 2013 required for every , page. 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 ears usage n/a-well in use 9 ( y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 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: 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): Septic Tank and 2 Leach Pits. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 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: Age unknown—system is assumed to have been installed at time of dwelling's construction in 1972. An overflow leach pit was added in 1987 per as built card at Health Dept.( permit 87-430). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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.): Sewer line is behind finished wall and not accessible for inspection. No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is imetal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 x 5 x 6-1000 gallon Sludge depth: 4 in 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 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 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 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? As built card 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 not required at this time, but maintenance pumping is recommended within and every 2-4 years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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-3/13 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 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 June 5 2013 required for every , page. CityJTown 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: Materia 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 90 Pine Street M Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 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 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.): 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. 1 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 ,M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Soils above leaching pits appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Overflow pit was uncovered and found to contain 6 inches of effluent. No staining at cover interface or in overlying soils was observed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert i Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins•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 GSM 90 Pine Street SVey Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 • Commonwealtti of Massachus'effs Ti 0D fficial in ion r a a Subsurtace Sewage Disposal,:=Syst'em:.Forfb Not foc Voluntary Assessments .90.PiN S,t.t Property Add a-s's, V1/ilGam and;MaryQ'e�ioe: - --- -- Owner owner's Name - inforrnation is requiredJorevery West Barnstable. MA, 02668, Juh.05i 2013 page. City/Town State Zip Code Date of.1 - tion: D.,System I nformatlibn '(cont.} Skefch Of Sewage DispoSaCSystem Provide avew ofth'e sewage di posal system, Including ties.fo at least two,Permanent reference landmarks or benchmarks; Locate;all"wells<within 1.00 feet. Locate where'public.water supply enters the buildiri°g. Check one of the boxes below; hand-sketch in the area below drawing attached separately, ?lT Q PT A S:�PTt G 3 ��2 ¢�z w 1 _ r P` � � G S•ii Z i5i6s•3713', TRie,5.Otficial inspeclign corm Subsurface Se wage.Disposal Sgstem:•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5 2013 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: 25+ 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: Town of Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater table. 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 M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for every West Barnstable MA 02668 June 5, 2013 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 L r Commonwealth of Massachusetts W Title 5 Official Insp ection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessmentsral 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 September 12, 2007 required for p every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name ab 43 Triangle Circle Company Address Sandwich MA 02563 E°g0 City/Town State Zip Code 508 364-0894 1328 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 maintenance7of on site sewage disposal systems. I am a DEP approved system inspector pursuant to-Section'1;5.340-of Title 5 (310 CMR 15.000). The system: _ -- ® Passes ❑ Conditionally Passes ❑ Fa Is ❑ Needs Further Evaluation by the Local Approving Authority , M r- S September 12, 2007 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. t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is P required for West Barnstable MA 02668 September 12, 2007 every 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank 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 t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for P West Barnstable MA 02668 September 12, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 x Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is p required for West Barnstable MA 02668 September 12, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for West Barns /� table MA 02668 September 12, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for West Barnstable MA 02668 September 12, 2007 every 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? One leach pit also uncovered ® ❑ 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)] t5-2760.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for West Barnstable MA 02668 September 12, 2007 i every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n1a Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system. [If yes separate Inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): n/a—well in use Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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: Last date of occupancy/use: Date Other (describe): t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for West Barnstable MA 02668 September 12, 2007 every page. City/Town State Zip Code Date.of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: 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, distrbutien-bex, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age unknown—system is assumed to have been installed at time of dwelling's construction. Precast leach pit added on 716187. Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2760.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for West Barnstable MA 02668 September 12, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 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.): No evidence of leakage or backup into dwelling was observed. Sewer is behind finished wall and not accessible for inspection. Septic Tank (locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Design Plan t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for West Barnstable MA 02668 September 12, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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.): 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): t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M °° 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for West Barnstable MA 02668 September 12 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 September 12, 2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: 2 ❑ 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.): Soils above leaching pits appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Overflow leach pit was uncovered and found to contain 1 foot of effluent. t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 r Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is required for West Barnstable MA 02668 September 12, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is West Barnstable MA 02668 September 12, 2007 required for p every page. City/ own State Zip Code Date of Inspection D. System Information (cont.) 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. LOCATIONS LEACH A B O PIT LE 1 21.5 f t 33.5 F t PH a T 2 25 f t. 3? FL 3 58.5 f L 54.5 F L 4 63 f t 75.5 Ft- 2 SEPTIC�o TANK o t A B EXISTING DWELLING # 90 PINE STREET NOT TO SCALE t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 90 Pine Street Property Address William and Mary Devine Owner Owner's Name information is P required for West Barnstable MA 02668 September 12, 2007 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 ground water: 25+ 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater table. t5-2760.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable �p THE 1p� Regulatory Services „SCAB Thomas F. Geiler, Director MASS. 9`b 1639. �•� Public Health Division Arf0�rp Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE i L0CATION le) �14 ke sitee t SEWAGE # ,L Vi AGE (ge51 gol g5 . 6 1(® ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY CW®6 t LEACHING FACILITY: (type) i5 (size) food NO. OF BEDROOMS J BUILDER OR OWNER Vt 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 facili ) Feet Furnished by era tech T its e--fl,0o LEACH LOCATIONS O } � LEACH A t 1 21.5 ft 33.5 ft 2 25 f t 37 f t 3 58.5 FL 54.5 f t J ! z 4 63 f t 75.5 FL ! SEPTIC a TANK o 1 ' A B EXISTING i DWELLING # 90 PINE STREET NOT TO SCALE.. Ir t - ' TOWN OF BARNSTABLE 1.6CATION qD R-n� S SEWAGE # J3ti -- � (� l VILLAGE Wo ASSESSOR'S MAP & LOT/�-3 INSTALLER'S NAME & PHONE No. SEPTIC'.TANK CAPACITY PO LEACHING FACILITY:(type) I reC Ce;)W (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE ,CO-LIPLIANCE ISSUED: z% r 4 4-7 VARIANCE GRANTED: Yes No 5 f ti �"., � / f 1 �� � y _ / �� �� � S� f � .. �/ � � ��' 4'�,, �� �`� �� Q� ASSESSORS MAP NO: PARCEL NO: 2 Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ..... ....... ................OF.......................................... ............ Appliratinn for Ilhgpau al Works Tonstrurtion prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............. ..... . . ......... ........................................................................ ........... ............. L lion-Address or, of -----------------k �� . ,ojk�.-•-•------._...---•-•---•----------- ........_.�o rt.t S ....... '/`� / wn A. ..Aa.----s a .................... Oil!� gr.. .�.74r---------------------.-----.---.--- �..�1�!.Ae.......`..j`...5.. .....�.....i.l;(...-•-------------.- Installer Addr ess UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.._...` ...............................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of persons............................ Showers P4 yP g --------•------•---•-------- P ) — Cafeteria ( ) P� � Other fixtures ------------------------------------•--•------•---•-----------------•--------••------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacityf®O�?gallons Length.............•.. Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Vidth.................... Total Length.................... Total leaching area.______---_-------sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Pd •---•---- --........................ ---------•-----......-----•..............-•----•----------......................................................... Descriptionof Soil 7/`.-e.....5�� ...................•------•-----------------------------------------------------------------------•--------•------- x V .--------------------•-------•---------•-••---•--------------•-----------------------•---------------------------------....------...---•------------•--••----------•--..._.......-----------•-•--._...... UW ------------------------------------------------ ---------------------------------------------•---••----•-•--------.I--- Nature of Repairs or Alterations—Answer when applicable......4y.� �---__.0v �'.:T_r-_!�_-���----- ! --------•---------------------------------------•----------•---•--•-----------------.....----•----------•----------------------------------------------•------------.....---------------........----•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T'IE of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has e isstyd by the board of he th. Signed .... 4^of..... ........................................... .......................... Date Application Approved By...... � ..--•-•-----------'" --------------Date Application Disapproved for the following reasons_________________________________________________________________________________________..................... - ......................................................................................................................................................................................................... Date PermitNo-------5_7......... . e:)------------------- Issued......................................................... Date i� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................... . ...........OF................................... , ppliratinn for Uhipa,ia1 Warks Tututruriiun rermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........................................................................................................... --•-•-•--------•--............----•------------•--..........-•---••---------...-•••-------......-- �j/�,� yL� tion-Address �j %f lot��h.::�....................................• .........`G ��^9-l..S ...o f rfl!'r '�* r........_._.......__ Installer Address d Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms........ ...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ........................................................... Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacitv!�00.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. -- Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--_-..___--_-__.-___--- f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•-------- ----------------•- O Description of Soil..................__i°z. 54 -f x ....................................................................... V ---•--••-------•--------•---------------•-----------•------•-------------•----------..........•.--•---------••--•-----•-------------•-•-----•-.....--•-------- W ............................... •-•--------•------..................-•----------.....------........................r---•- U Nature of Repairs or Alterations—Answer when applicable....__..h �?:��..._..U�r �:.? �`Pu -------------- ------------•----•-•------•---•-------------------•------•-•----••-----------------....-----......-•--•---•-----•-----------•-----•------•-•---•---•-----------------------------------•--------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTTI a 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued by the board of he -1th. Signed-------=---------- - =.....✓` � ..---------...------------ ................................ Date Application Approved By.............. ------mow...._._�!Y_._....r.�_.__..... ........................................ Date Application Disapproved for the following reasons:-----••-------------------------------------------------------•-----------------•------------------------------ -------------••-----..........••.....-•-...----•----------•-•-------•••....----------•--•--------------...----------------------•------------•-----------••-----------••-•-----......................... Date PermitNo.----- 2..:.......-----'1.0- ------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF..................................................................................... Trrfifiratr of Tnntplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired �. �i Installer at--------------;Z r. ....."= -�- { ":_:_ 1. 2 .,_� .�. 'rJ��' - k has been installed in accordance with the provisions of T T T IE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....K.T.-...q-_2-111-2......... dated__-......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. �(\ DATE... .... -(,�•" Inspector.-., t d--��l ✓` ` , - ------------------------------••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........a r r� -:...........OF.........?�i.`q * r.�s ..................................:. Disposal Works Tono#rnrtiatt ranfit Permission is hereby granted......cw M�0,-�........�:�::��-�� _____ --------------------••-----------------....----......... ?Ito Construct ( ) or Repair (,<-) an Individual Sewage Disposal System Street ( _ as shown on the application for Disposal Works Construction Permit No.� :............. Dated......................n.................. 1 Board of Health DATE................................-�. ......................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS No. -- L---- - - Fee--c2- 5--------- BOARD OF HEALTH TOWN OF . BARNSTABLE ZippYication-*rVerr Cmtructionj3ermit Application i reby e,for a ermit to onstruct (-/ Alter ( ), or Repair ( )an individual Well at: - ----- ---------------------------------------------------------------------- \Location p— Address Ass�essors M p and Parcel Owner Address - �_ ---- --- ----------------- - -- � =---�-� - - - -- --- - --------- ------ Installer — Driller Address Type of Building Dwelling 1'Y ---------------------------------- Other - Type of Building - No. of Persons---------------------------------------------------__ Typeof Well-- --- - Capacity------------------------------------------------------------------------------ Purpose of Well------- - --�.�C3 --- ----- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well,Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed --- ------------------ ------------------------— ------ ---------- date Application Approved By- ---- - ='(�-►- - - -b — da tf Application Disapproved for the following reasons:-----------------------------------------------------------------------------_------------------------ ------------------------------------------------------------------ ----- --------------------------------------- -------- ---- ---- ------------ --------- ------- ------- ------ ---- date Permit No.--- - - --- -- Issued- - 1 5 -- -- -------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS IS TO ERTI Y, That the /IrWiv"id�uaal 11 Const u ted (✓, Altered ( ), or Repaired ( ) by---- -�� r -l N��cX.lL -------- -- ---- --------------------------------------------------------------------------------------- at- -o- PQk --- _�- ------ ---`-----------------------------------------------------------------------has been installed in accordance with the provisions of the Town of Barnstable Board of Heal Private Wellrote too Regulation as described in the application for Well Construction Permit No. W-qj!!9-0L`Dated--= - -�J'_ _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------—-------------------------------- Inspector—-------------------------------------------------------------------------- No. I /_ /CT � Fee—r12 _—------ BOARD OF HEALTH { TOWN OF BARNSTABLE F } F Z•pprication-*rVell Con5tructionpermit Application is-here by made for a permit to Construct Alter ( ), or Repair ( )an individual Well at: - =-9'0 _��,� , =" ! -?-bran�►� —-- - -- - - -___ _- -_-_- _—___ Location — Address Assessors Map and Parcel r � 11 Ptl_�,��S4. . Owner �Address— Installer — Driller f�r ( , Address - Type of Building v Dwelling ------------ E Other Type of Bu"lding —':-_ - — `-'- ,' No. of Persons=-- - 4--— =` _-- --- Type of Well-- = — Purpose of Well-------Lj- ='" -( _____—_ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation untillaa Certificate of Compliance has been issued by the Board of Health. Signed '-— — ' - ------------- —_--- R _ • date — �i l Application Approved By-- ,R date Application Disapproved for the following reasons: --------------—------- -- - ___-_----------------------------—___-416 — --------------� • date _ Permit No.— �_! °—/ '--_—___ Issued -- 1�- -r—3—— -- -- T date BOARD OF HEALTH TOWN ;OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Const�ju/c�ted (4, Altered ( ), or Repaired ( ) bY------------d-1 �1- ==� - — l Q_Q Q #-------------- Install has been installed in accordance with the provisions of the Town of Barnstable Board of HealthPrivate Weelllr Ijrotecttion Regulation as described in the application for Well Construction Permit No. -`-Dated----�j- �--�- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL . SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------- ---- -------------------------_ — — Inspector- - — --- —- - - ------------— -- r BOARD OF HEALTH TOWN 0F BARNSTABLE' Vern Con5tructionpermit 00 Q cS J No. ---�-—- /_- Fee Permission is hereby granted-------L � = = ---Lj 0 J��_f-1_- to Construct Alt�r ),fVr Repair ( -) an Individual Well at: — - ------Street as shown on the application for a Well Construction Permit No - �� - --- ----------------------------- - --- - _ Dated, . j ",1, -) , M Board of Hea4 DATE ----------------------