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1917 SERVICE ROAD - Health
1917 SERVICE R'GIP 0 lip J ys Commonwealth of Massachusetts f), Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 1917. SERVICE-RD Property Address. 0 ROGERS,XENNETH P n Owner Owner's Name inforfraatian is -a required for every V14ES T t3ARNSTABLE MA 02668 2-122119 page. ity:Town state Zip Corse Cate of Inspection j* inspection results must be submitted on this farm. Inspection forms may not be altered in any way. Please see completeness checklist at the and of the form. 1Mr,0Ftant:When / filling out forms _ General Infori att n. on the computer, use ordg tt<e tab key to move your 1 Inspectors cursor-do not Robert Paolini use'thee•feturr --SASS---_.-----------SASS-- ---------SASS-- ----- key. Name of inspector Robert Paolini Septic Service Company Name 17 Playground Lane n Company Address Yarmouthport MA. 02675 City/T.own State zip Code ..508 3.62-3555 S14454 Telephone Number License Number _. -B Cpif c.at'ion 1 certify that'l 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. ''he•inspection was performed based on my training and experience in the proper function grid maintenance of on site sewage disposal systems_ l am a DEP approved-system inspector pursuant to Section 95e340-Of Title 5(310 CMR 15.000).E he system: EXI Passes VD Conditionally Passes ii_I Fails Needs Furthe - lua by the Local-Approving Authority L � V2211.9 inspector's Signature Date The system inspector shall submit a copy of this inspection report to the-Approving-Authority,,(Board- of Health or CEP)within 30 days of completing Ttis inspection. If the system is a shared system or has a design flow of fi0;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 des-cilibesconditions at also tii®ie of inspection..and under the conditions€af rise at that time.This inspection sloes not address flow the system will perform in the future under the same or different conditions.of.use. Title 5 Qffidsl Inspection Form:subsurface Sev-age Disposal System-Psge 1 of W t5ins-11(10 Commonwealth of Massachusetts Title, -5 Official Inspection Form Subsurface Sewage Disposal System Form Not for VWn otary,Assess ments 1917 SERdICIE RD Property Ad&ess :R4DGERS,KENNETH P Owner Ovaier's Name -infi)-mation is 'required for every WEST BARNSTABLE IVIA 02668 2/22/19 page. city/Town State Zip Code Date of Inig?ection S. -Cerfifi C.otio n..(cont-) Inspection Summary. Check A,B,C,D or E I always complete all of Section D A) System Passes: EXI I have not found any information which indicates that any of the failure criteria described in M CMR 15.303 or in,310 CMR 15.304 exist. Any failure criteria not'evaluated are indicated below- Comme-its: B) System Conditionally Passes: ❑ One Dr 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_ Checkthe box.for,"Yes", `no7 or"not detefmined" (Y, N; RD)-for the-lollowingstatements. 1,inot.- determined,'!olease exotain- 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 exf.iltration or tank failure is imminent. System ystem will pass inspection if the existing tank is replaced with a complying septic lank as approve-al 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 L-1 ND(Explain beimpi)- ffiris-I VIG Tifte 5 Glfiaisl-lrisWctbrr Form-SLbsljl&,,ce Sew-age Dispcs2f System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 191-7 SERVICE RD Property Address .ROGERS, KEN UET-H. P Owner Owner's Name Wormation is WEST BARNSTABLE MA 02668 2/22119 required for every page., City/Town State Zip Code Date of Inapection , -C I B,, _eAtfic on cat. _(contl B) Systern Conditionally Passes (coat.); El 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 pipes) L box. System will pass inspection if. (with approval of Board of Health),. El broken pipe(s) are replaced DY El N El ND (Explain below): El obstruction is removed El Y 0 N 0 ND (Explain below" ❑ distribution box its leveled or replaced EJ Y El N El ND (Explain below): E] The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The systdm w:ill'-pa5--, inspection,i-'.-(With approval of-the Board of*Health')*. El broken pipe(sl are replaced L1 Y 0 N L1 ND (Explain below): Lt. obstruction is,re mLved. FI.Y 0, R 0 MD (.Explain-belavlO:. C) Further Evaluation is Required by the Board of Health: El 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. Systern will pass unless Board of Health deterrytines,in accordance with 310 CWtR 15.303(lxb)that,the system is not functioning in a manner which wilt protect pubric hoe-th, safety and the environment- ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-.11110 Title 5-Official ifispecton—Mirm:Subsurface Stwage Disposalsystoill-Page 3o:17 Commonwealth of Massachusetts Title 5 Official InspeCtiGn FGrm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1917 SERV rCE RD Property Address ROGERS, KENNETH P Owner Owner's Narne information is required for every WEST BARNSTABLE MA 02668 2/22/19 page. Cit ty/Town State Zip Code Date of.Inspertion 2. System will fail unless the Board of Health (and Public Vlater Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and-er-Mronment! El The system has a septic tank and soil absorption system (SAS) and the SAS is within 100-feet of a surface water.s. upply or tributary to a surface water supply- LJ The system has a sep6c tanK and SAS and the SAS is within a Zone I of a public water supply- El The-system has a sepfic tank and SAS and the;AS is within 50 feet of a private water Supply well- F-I The system has a septic tank and SAS and the SAS is less than 4 1 00 feet but 50 feet or more.from-a.private.water-s-uppiy-well* Wethod used lo;dMermine.-dislance- This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and-the presence of ammome n ftgen-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. I Other D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"toeach of the following for afl inspections: Yes Ulu Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El :1,11 Discharge or ponding of effluent to the surface of'the ground or surface we-ter-, due to an-overloaded-or clogged-S-AS-or-cesspool El Ex. Static liquid level in the distribution box above outlet invert due to an overloaded -or clogged-SAS.or cesspool Uquid debib in cesspo6i,-is"-tess'than.'6".-below-,inve--,rI-or-aveRable volume-is I—es's than 1/2 day flow rSh 14/10- frar-Tudon-Forar.-SubbLahm Snmaqc Di at Sys r Pagic 4 oFIT Commonwealth of Massachusetts Title- 5 Official- InspectiGn FGrm- Ilk 4 Siibsurfilice.Sewage Disposal System Form Not fior Voluntary Assessments 1917 SERVICE RD Property Address ROGERS, KENNETH P Owner -Owner's Name information is required for every WEST-BARINSTABLE JVIA 2/22/19 page. 134-IT!own -stale Zip-Cane Date of Inspection Yes No El FS I 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_. El FT Any portion of cesspool or privy is-within 100 feet of'a surface water supply or tributary to a surface water supply- El IN Any portion of a cesspool or privy is within a Zone I of a public well. R .-Any-porflon-of a cesspool-or.pri.vy is-Within 50feet-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. FT his system passes if the well water analysis, performed at a DEP certified laboratory-,forfecal cofform 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, and7chafnt oftusstodj must be attached to this fiDirm-1, The system is a cesspool serving a facIilv with a design'low of 2000gpd- . 1, 10,000apd- L1 Ex D The system fails. I have determined that one or more of the above fail'ure criteria exist as described in 310 CIVIR 15-303, therefore the system fails. The system owner should contact the Board of-Health to determine what will be f ieceeszary to°correectthe,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"ves" or"no' to each of the following, in addition to the questions in Section D. Yes Nb D El the system is within 400 feet of a surface drinking Water supply El F1 the system is within 200 feet of a tributary to a surface clinking water y sup- . pi Ej the system is located In a nitrogen sensitive area (Interim Wellhead Protection E] Ar-ea--IWP-A).-oi-,a:,-riappeul." S" to any question d If you have answered "ye estion in Section E the system is considered a signif cant threat, or answered"yeg"'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 T16 S.CffiziaHnsjection:Fwrw-Subsurface GoviaG&Disposal;raystEin.-Page 5 of 17 Commonwealth of Massachusetts y3. Title 5 Official Inspection Form . - Subsurface Sewage Disposal System Farm 6 Not for Voluntary Assessment's 191- ,SER\ ICE:R-D Property Address ROGERS, KENNETH P Owner Owner's Name information is N,E BAR�ST�BLE �:��1 L�2 21��i10 required for every page. CityTTown testate Zip code Gate of inspection C-. .$ a+ 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 awner, occupant, or Goard of Health ❑ r�x Were any of the system components pumped out in the previous two weeks? ❑ 1J Has the system received normal flows in the previous two week period? -gave'.aroe-v-oiumes-cif water been-introduced to tie system recently or as part of this inspection? 'Were as bull:glans "tune system Obtained end xarn:n 3f:}f ey,sera not available note as N! Was the facility or dwelling inspected for signs of sewage back up? EA]. ❑ LNas the site-inspected for signs of break-out? ❑: Were-al[:.&ystern cOmpone tts, exciudi g the SAS, 10 4ed'crt 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 sum? Was-the"facility-ow—ner(and occupaMs.if.differentfrofr_auner)._providedwith -infan-nataon or3" e.Proper f-naintianarroe of subs€ff face sere disposal syut s? The size and location of the Soi.I 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_fie';d.(if any.-of.the IfFailure cri rra..related}£3 Part G is at issue approximation of distance is unaccapfable)[�10 i�fIR 15."sFgz(o;� -D.Systern In formation Residential Flaw Conditions: flltrier bedrpe.z .{ciet�a. ;: Nurx�,ze,..of# lr :#az13: 2 DESIGN-flow based.on.31.0 GIVR 5-203(for example: 110.gpd x#of�edroorrs.): 430 ins-9.1 N0 Title S Official Inspection Eo":Subsurface Sevbge Disposal System-?age 6 of 17 Commonwealth.of Ml chusetts Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1917 SER-VICE R€T. Property Address ROGERS, KENNETH P Owner Owner's Narne iequiron required for every WEST BARNSTABLE MA 02505 2/22/4 � page_ Cityr'Town state Zip Code Date of Inspection D.-SrAemInfonnation Description- 9 Number of current residents. Does residence have a garbage grinder? ❑ Yes ; ? No is.ia � s , . , � � ; :, ;N Laundry system inspected-2 ❑ Yes_❑ rho... Seasonal use? ❑ Yes No .!!dater meter readings; ;if.available,(last 2 years.usage(apdr): Detail' -&,jTTxP plow A :Y-es.r l 1 NA Last date of occupancy: Date Con—mercial/industrial Flow Condition-s type of Estgb;Elsnment: Design flow{based car 31.0 CMR 15.2031 Lallans per day(gpd) Basis of design flow.(seats/persons/sq.ft.,etc.). Grease trap present? ❑ Yes;D ,No industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑" Yes ❑ No Water imater..read ngs,,if available:. .f':#S75-iSffQ' Title,rJ Official'inspection FOi'iTf:uitb5131f3C8: g8.D15P05 i.$yStF.tPi+[?.yge 7- -:57 r Title 5 Official r r \ . �. rice Sewage �zpoai: ystern_t=dot-- Not for Voluntary.s .� ..Propertj Ad-dress ROGERS, KENNETH P Owner Owner's Name ato �l22/19req&gd for is WEST.BARNS:'ABLE MA 0268 .page. Cityffown State Zip Code Cate of Im5pection a/26/1 Last date-of occupancy/us&.:" Date Other,(dascribe befow'}: General information Pumping Records: .:Source of.information: Was system pumped as part of the inspection? LXl `!es ❑ No if yes. Volume pumped g 1000 ons How was quantity pumpo-d determirv6d? measured Reason fcr pumping: Type of System; �] Septic tank, distribution btu_x, sail absorption system L Overtlow cesspool. Privy Shared-systern (yes or na),(if.yes. attach prev.ious,inspect.ion records, if any .. innovative/A"Iternative technology. Attach a copy of t'le current Cper cab n and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the IIA system by system operator under contract Tight tar*- Attach a copy of the DEP approval. ID Other(describe): fps.•5 if?v Tole.5 Official:Inspacbm Form:Subsurface Se ge Ompa-5m Sq;em•Page 8:e:1 } = Official - rorm F . Slubsuifaoe Sege Disposal System Form- NoffOrVoturttaty Assessments 1017 SERVICE RD Property Address ROGERS, KENNETH P Owner Owner's:Narne requiredora e WEST BARNSTABLE INAA G2t�s3 2/�110 required for every page. City/Town state Zip:Cade Date,44<aspee;on - {Conq fi Appraximate_age of all components,.Cute installer {if known).and Source C3 !1iGrmatiGn: Were sewage odors detected:when arriving at the:site? C Yes C No Building Sower(locate on site plan): Depth below grade- 1.5' feet Material of onstructichn: E cast iron EI 40 PVC i other{explain): 10 Distancefram private water-supply well:or s.tctioa ifie:, �et+ Comments(on condition.of joints, venting, evidence of leakage etc.): joints appear tight.No evidence.of.leakagr..S.ystem,vented through.the douse vents. Septic: Tank.(ioc ate on site. plan): Depth below grade: ..feet Material-of construction: n concrete metal ❑fiber n pol tr�ethylene 1=1 other(oYpla;nf If tank is metal list.age: :years Is age-confirmed-by a Certificate cf-Co!rplianc-e?(attach a-copy of-certificate) -Yes C) \to ..Dimensions: 000 rt Sludge depth: t5r...°t°:ItQ Syster•Page 9of 17 Com:m_ onweafth of Massachusetts --a - Inspection Form-n _c 9 - T 1& 50ffi i t 01- Subsurftce Sewage DI'sposat Sotem Form Not for Voturttafy Assessments 1947'SERVICE RED Property Address ..ROGERS,KENNETH,P Owner's Name information is TABLE M A 2/2019 T 'irect,for-every WEST BARNS 02668 -page- City/Town state ZIP Code -Datie of:inspection .y 16 Septic Tank(cont roll Distance from top ulfsludge to bottom of outlet tee or baffle Scum thickness Distance-from top of Scumn-to too of outlet tee.or.ba e, Ustance from bottom of scum to bottom of-outlet tee or baffle 'How vvere dimensions determined? ffleacured -Comments"on pumping ping recommendabons,Iritet and oW.et-tee arse condifion, structural inteig"it liquid levels as.,elated to outlet invert, evidence-of. leakage;et`-__Y Pump tank every two years-Inief and-outlet tees are in place-No evidence of leakage.. Grease Trap(locate on,51te..pian). Depth below grade: -feet Material'of construction.- 01 concrete metal 0 fiberglass. 0 polvethylene other(explain): Dimensions-. Scum thickness Distance from.to n-scAim.to.toP of outlet I e or baffle - Distance from bottom of scum to bottom of outlet tee or baffle Date of last--pumping.- t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Cori irn.onweafth of Massachusetts pection Form ti,, Title 5- Official Ins Subsurface Sewage Disposal System Form Not for Voluntary Assessments AGE RD 191TSERV Property Address -ROGERSj<-E,NNETH.P seer �wlefs Warne 'Ti-nefqormation ies VVESTBARNSTABLE IM D268 2122/19&Ed fOT very page- City/Town state Zip Gode Date of inspection D..'syste.m,lfffomutl-oil �CoTit.) omments (on pumping recommendations, Inlet and outlet tee or baffle cundit,on, structural integ.-t liquid.levels-as relatted Io outlet invert, evidence of-!eakage.,et--.)... Tight or Holding Tank (tank must be pumped at tittle of inspection' jocate, on site plan�- P Depth betow grade-. Material of construction: F_-I concrete El M=tal fiberalass n polrethylene othar',explain'- Dimensions- Capacity: Design Fio*vv. gaWns fAr day Alarm present: El Yes M, No Alarm level: Alarm in working order: Yes '-No Date of!ast pumping.- Dote- Corr meats(condition of alarrrr aftd float switches, etr-- *-Attach..c;qpy of current,pumping contract quired-as copyattached? 0 Yes FJI No tl-;-ns-11110 Tile 5 Offidai hispechor Form:Sub�urfau- Page I 1.,c4=7 __-omrnonweaVh W MlassachuseVts tte" 5" Official I n. spection Foy Subsurface Sewage Wspo-sal Sys,- Form-Not for V,oluntary Assessments MTSERi<VCE RF3:. crop}rty;c res .ROGERS,-KENNETH P Ownar o vn&s ire information is reayuired for every =�,11i'EST=B�F:IS AB fi C;2 8 �9 page_ Gityffown State Zip Cazte Gate of InspeoOn D.System InformAtion 1cont.) Distribution Box(i present gust to opened; "locate on site plant: Depth of liquid level above outlet irrvert- no Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, ant ev�ide-ice of l a tit€,o€ors of etaw. ° Box is level-Box has one outlet lateral.No evidence of leakage: P F,%. a �e€;locate Jti site Plan;: -Pumps in working:or r: ye-5 C No Alarms in working order: Yes -No .Comments.(note r ' 1t!^'1,L'-f. ':Fa!'i .. y� '-.�''}�'er,:r nd�tt7'-,1 of-Fi,im�s and?ppi.�-�,_n r'=.!cS;_ct .a. .'Soil A so tion System (SAS-1 (locate on Site plan, excavation not requi ed): If SAS not located, explain why: c.,-,a c 6.n_. 1 1!'� Tic 5:�fi+i I i _:e c;Form..- �_; i{ �, C; x=x_i=;-.cr; rc 1 c Massachusetts Form :� f��; 'Ee P s :.Sm.Form Fact for tfi hu ry Asses rite tis 191 T SER(TCE RD -Property Address ROGERS,.KENNFT.H.P owner c�.avnr r'_s Natn2 informa5on is � tt -,b e ery VVEST3APMSTABLE A (2 68 ZQ2/1.9 {rake. city%fn an #a#E Zip Code Date cif In'-pedion 4ype: Q: leachingp}ts. r�}mber. . Uxo with c stone ' Teaching chambers number. ber. IPac-hing cal ie_ r-umber_ eac I ing Ar-Winches number,length- leaching.fields nramber,-dimensions: -- .E overflow cesspool number: Li innovat;velalterna iVe system Corr menu(note conditiol,of soil, signs of hydrauliG failure, levef of pondfing, da;np.soil 1, condition of vegeta",ate Sandy soil.no signs of hydraulic failure. Water(ever 40"below invert.No stainline higher Cesspools ;cesspool rust be pumped as part o,ir:spection.' ;locate on site plan;: Number and..con iguration Depth-top of liquid to inlet invert „ epth,ref:solids layer Depth of swmi.,layer- Dimensions of cesspool Material's of construction Indication of groundwater inflow Yes -No >y.t?.ip r 'Strri!lnsw-a.�n-fnr„;ssrs :; ri ,yr •#?�Sa:.3 :1 E I ts t. t �:t , 1917 SERVICE RCS R-eDery Address :ROGER&-KEN ETH-P c wnw --'Omer s Name wtrvrrr aftort js {��('�'[� r9 lilr:3(i-foT:-F3Uf?T'ij V4i/EST$ARNST�aL ZLf.i . page. C-Ay/Town 5taf? Zip-Code Date of Irtsnei%on D system nformabon 1cont.) fc note d- P sod, -4 r h r afailure, e' r= eta fio -o- mmen.. ( ote Grp::tiG. of $of t � 1!!CcV of Neil iri , %Ci GitiGt of @t i C. , etc:}, Privy (locate on site plan): 'Dimensions .Depth -of solids Corrireits-lnote conditionarl abil-sicin: of hydraulic failure level of poncttng, condition Cyr v etatiom etc:V t5i •11110 T tic�C=fi_:ia_InsfiolArn i:un= Sul-a rf3c_ in! onn... Pr rwrM. t- Surface for.V1 -s- awnts E'R V In E RD A d d r F Othiner infer- -Li ZT 'RH -TDT every um.. A FiC.4, VI&W -_wage referep rri ,Flit ,v. h thP h the ar O ion, mormealth of fe assac hose is sewage Df-sposa--."tYstem--Form 11G4.W 1Ey.FF+d7-ib ry Asses 7Tment:7V.- 1.9.17 SERVICE RD f�rc.�ert=.�dc�,ess GERS,`-KENi:NETH P Owner Owner'sName uatormaban-is ' T BARNST BE , �? rec�tise€3'.tCrr every page- kylTown Mate Z+p:r c date c?fi?� eC#sor D. System. lnfor a= n.,4cont Sits Exam: 0. Check:Slope, Sirrf ace water: Q Check.cellar L1 Shallow wells fi #e�deptho.:"rt grrirer: feet Please indicate.all methods used to determ.ine the high.grour�ci vatecelevation: �c:ained from ys-L-U-Jersign plans?on I0-cord If checkl-d, datee of deSign:;p an.revjewed::_ Rate: Observed-'site.labuitinc�,prepert}°Cbbservatibr V e within 1 fbeE`ef SAS):: !u!. r„heck--dw;l Ie I d?e^rd of l•Ie^lth-explain: =B ;Gimsf-k fth—t r�xca� rs Itefs-'�att✓aeh r�rsW er at -Accesse&USGS database explain: You- ustdesk itea th6 you eastabr `s d-the=ttlg=_Y ground water ele-v iom t7SED:USES 0bserva€ion:Well 1Yata.U I :Technical`l3 tliebn 9Z=1 t F anrruat ranges-of groundwater elevations.. Before tiling this Inspection Repot, please see Reporl.Completeness Ch_ckilst oil, i t page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage-Disposal-System•.Rage 16.of 17 i Commonwealt Ties 5 Offiva1 tfispection, off' Subsutf Ace Sawage Dij%POS4 System-For-Not for, (*n�. . Assesunenf 199:7_ SERVI.GE.RD ROGERS,KERN ETH E Omer -OwneVs'Name �torrt?at+o*r� _ ..page. ?y Fflwrs State c p-Gaue ate-,6 A ISP 17'c=ien E. #deport Completeness Checklist u inspection Suns mary: A, I;, CU, D, or E cheered Q'. Inspection Summary D(System Failure Gtit*iaApp,4cabI to Att S�terns"comoteted, ay eair.Irfio�rt ticrt:-E�tstE�ataddepth,to_high-Toun a{.e=. lel C{fit I "_ f .J 3a3� a T ejtmeT avvm on pag- c I_ci or attcL-hed-in separ e fi'le Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 page. Citylrown 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 J14 key to move your cursor-do not Richard T. Johnson use the return Name of Inspector key. D &J Environmental Services &y Company Name P.SO.Box 764 Company Address Buzzards Bay MA 02532 Citylrown State Zip Code 508-735-8740 S113545 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 in{spection.the inspection was performed based on.my training and experience in the proper function and:maintenanLe of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant too Section 15.340;of Title 5(310 CMR 15.000).The system: =' ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12/21/13 lnspeAWW1g`n`at4e 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. ge Disposal System•Page 1 of 17 t5ins•3113 Title 5 Official In spection Form:Su Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria a not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owners Dame information is required for every West Barnstable MA 02668 12/21/13 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•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Ma ssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 page. CityrFown 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner owner's Name information is required for every West Barnstable MA 02668 12/21/13 page. Citylrown 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 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owner's Name required for is West Barnstable MA 02668 12/21/13 required for every 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '< 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: n/a 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:SubsuAace Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1984 town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5' 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.): joints structurally sound, no signs of leakage. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts luTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owners Name information is required for every West Barnstable MA 02668 12/21/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Field measure/MFG Specs. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete baffle in good condition, tank structurally sound, no evidence of leakage. Recommend pump system now&every 2 years going forward to extend life of existing components Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): l 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Jy� 1917 Service Road Property Address Robert Bono Owner owner's Name information is required for every West Barnstable MA 02668 12/21/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•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 '< 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 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 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box level, structurally sound, no evidence of carryover. 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 orders stem is p p g y a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 1x1000Gal. 6 x 6 ❑ 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.): no signs of hydraulic failure, no damp soil, normal vegetation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1917 Service Road Property Address Robert Bono Owner Owner's Name information is West Barnstable required for every MA 02668 12/21/13 page. Cityfrown 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 alp g c 4 rA 9 P�3 37 8c 33 t5ins•3113 Tula 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 1917 Service Road Property Address Robert Bono Owner Owner's Name information is re West Barnstable MA 02668 12/21/13 c,uired for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water. 12+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Obtained from site observation, visual elevation, examined abutting properties on file at BOH. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3/13 Title 6 Official inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 1917 Service Road Property Address Robert Bono Owner Owner's Name information is required for every West Barnstable MA 02668 12/21/13 page. City1rown 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•3113 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 17 of 17 44 r ® 0000 ' COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500. TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 191.7 SERVICE RD. WEST BARNSTABLE, MA 02668 M194 P108 L6 Name of Owner ANITA ST.ARMOND Address of Owner: 68 AMELIA WAY MARSTONS MILLS MA.02648 Date of Inspection: 5/17/00 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 508-664-7270 CERTIFICATION STATEMENT 1'certity that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes _ Needs Further Evaluatio y the Local Approving Authority Fails Inspector's Signature: Date:6/21/00 The System Inspector shall sub It a copy,of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life" THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1917 SERVICE RD.WEST BARNSTABLE, MA 02668 M194 P108 L6 Name of Owner ANITA ST.ARMOND Date of Inspection: 6/17/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any Information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. 121A The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exFiitration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n/a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced n(a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): broken pipe(s)are replaced _obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1917 SERVICE RD.WEST BARNSTABLE, MA 02668 M194 P108 L6. ,Name of Owner ANITA ST.ARMOND Date of Inspection: 6117/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)_THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance Wa(approximation not valid). 3) OTHER n!a revised 9/2/98 Page 3 of 11 P 88 573 Town of Barnstable P# r a-S' V/ Department of Health,Safety,and Environmental Services -Des:Jo 2"7 Public.Health Division Date 1 -/5 367 Main Street,Hyannis MA 02601 S wnvarABM • p ' ''�� Date Scheduled I ^ t — / 7 Time I& Fee Pd. en t�ta+ Soil Suitability Assessment for Sewage Disposal Performed By: D6W 01A LA (_J)DWIN) QWC**W,� Witnessed By: -T&P.fL-Y �VNN1 LOCATION& GEN RAL:�1F.. ATION Location Address 1 D� Owner's Name "PFL607,6<— 000 w ft �a•-f?mLr Address Assessor's Map/Parcel: 1, Engineer's Name e/;&_krV&&fL4 N NEW CONSTRUCTION V00- REPAIR Telephone# _34? —W 5 4 0 Land Use �I C. A/`rT6 Slopes(%) S Surface Stones "-I/ Distances from: Open Water Body X ft Possible Wet Area X _ft Drinking Water Well ft Drainage Way ' , ft Property Line `t' ft Other ,k_ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) �fZ✓ILC 'IZo'.�1`D 0 M LCFT 8 0 .0 to� I o«,-TA Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater R4:K w 01iN-b ETENATtOIri 'O SEASONAL,HYGH'V�ATt;TAt3E ... Method Used: Depth Observed standing in obs.hole: N/A in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ I'ER+COLATIOI'�i TEST uate 1 1 G►Observation / Hole# �} `� Time at 9" e Depth of Perc —Tz p r' 45 Time at 6" 3o Start Pre-soak Time @ '�' Time(9%6") �3d End Pre-soak 14 ` 017 Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) I V Original: Public Health Division Observation Hole Data To Be Completed on Back---� Copy: Applicant DEi�r Oflsgk"TION 1*1 LAG Holy# 1 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(m.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. lConsistengy.% 0--L O 00"N1t. t,04" SAND I0` fL 5/B M6D/F 1_ � ING— ?G- 12o G '6aNv r.ob1�� 12n• 1 G2 51a CAM` 2.�-r 4/2 ('+MnoJe."1 f oc�Lat5 0q G1y lokvv. DEEP OBSERVATION HOLE L!DG Hole;#, 2» Depth fto i Soil Horizon Soil Texture Soil Color Soil Other Surface(m.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. 04 Gravel) . DEI� OBSERATtN lt( LEbG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface Mottlmg Structure Stones,Boulderes. ) (Munsell)(in.) (USDA) F DEEP OBSERVATION HOLE L(�G Hale i# Depth from Soil Horizon ' Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. o DEEP USERVATIbN IIOLE L(�G Holy Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Town of Barnstable P# V 9 8' S O. Department of Health,Safety,and Environmental Services -DCC- Jog �'16-yu Public Health Division Date — 1,5- - 9 7 367 Main Street,Hyannis MA 02601 IA MA11M KAM 6 ►�� Date Scheduled 1 -- ( 62 — 7 Time l0 Fee Pd. /O -6> Soil Suitability Assessment for Sewage Disposal Performed By: N J/411) l >WN (A� gw�,w�- itnessed By: Ste+)w- • t.( CATI �1&;GEIVERAT� 'ail UI A . _. . : Location Address �-07- -7 Owner's Name CrE �j 2'�, w �N��_ Address� Assessor's Map/Parcel: �'�L` Engineer's Name SOW/J rI ( rNjc,_ jEC-T1-\N�i NEW CONSTRUCTIO N �✓ REPAIR Telephone# -.561 . Li 5 4 Land Use �/t ro'� Slopes(%) © 45— Surface Stones_ ALJ Distances from: Open Water Body _ft Possible Wet Area ^ ft Drinking Water Well X ft Drainage Way X- ft Property Line ft Other }� ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 1 8 L.0T � g M ' THtIo� -*t E- 5,01 T 37' 170.2°� Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: !a p �Weeping from Pit Face A t Estimated Seasonal High Groundwater Al o RVN_.-A4 1�rL- FV 01> ETE NATIt�I '( R SEASUN HYGH'VV ')~ T l l Method Used Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ pERCOLATIfI� TEST Hate >* 11me Observation �' ��,I /__T142 Q l Qd d;00 Hole# Time at 9" Depth of Perc 4b', S y U Time at 6" Start Pre-soak Time cQ Time(9"-V) End Pre-soak RateMin./Inch Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back'�j Copy: Applicant DEEP OATY01�1 I-IOLE I,OG Hole'## Depth from Soil Hori 1.zon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling fStructure,Stones,Boulderes. % ell Z�6 A 6AJ\M-( W00A -7.S i iL y/2 MAD/ I"Is- 7 84--110 G 2 SAN't�t.�A M �,. �( L/s. v 9ANolr wAfA u 120- 5G LTj L0N6Eb ot: �iar. 2.•5 DEEP OBSERVATION HALE L+C)G Hole# .:T '�». �y��awH'er�0 _. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(m.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % s�q Mc Afc-., -T-+ 2. t;. BEEP OBSER ;ATIONIb .E ,( G dole# Depth from Soil Honzon Soil Texture Soil Color Soil Other Surface(m.) (USDA) (Munsell) Mottling [Consistency.Structure,Stones,Boulderes. % V' TION HOLE LOG Hole DEEP SE A ... Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(m.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % 4 D bBER ATI011 IIOLE IJG Hole -. .. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(m.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % i JI Town of Barnstable P# j? R�S Department of Health,Safety,and Environmental Services _Xf='bD W °I6-L)25 Public Health Division Date 367 Main Street,Hyannis MA 02601 S uxrrereera, t M� Date Scheduled—T/ /� — / 7 Time Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: DIN t-Do �CN�1N•) Witnessed By: LO;CATI( N & GENEI2A�.Atli� t1VIA `tUl Location Address f Owner's Name �c.1 'p-(�.oPtn�1 E5 'JZ.� W,.'�1� NSTA`3l.EAddress C. Assessor's Map/Parcel: 1-7-1 Engineer's Name ENG-\(`ram \N!i NEW CONSTRUCTION V REPAIR Telephone# '7,7(,-L^y 5 Li I Land Use V Jkt A NT Slopes(%) Surface Stones P--W Distances from: Open Water Body ft Possible Wet Area .< ft Drinking Water Well ,�/ _ft Drainage Way X, ft Property Line ft Other T ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) t 63.©o i . I 3Z 40 1-71, L Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: �Weeping from Pit Face - Estimated Seasonal High Groundwater �/ Ho . DVATEtAb A SEAS -A Y O T ..... .E . .. Method Used. Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PER+COLATIOIi TEST Date 1 7,mel Observation Hole# T 11+?— Time at 9" 01,00 t,00 et � Depth of Perc -M� '� Lif _ Time at 6" 2 Start Pre-soak Time® 0 `00 Time(9"-V) -2-1 1 End Pre-soak t @� �.Z. Y1��~/1 Y► Rate Min./Inch Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) ry Original: Public Health Division Observation Hole Data To Be Completed on Back-•—� Copy: Applicant DEEP OUSERVATION OLE I,0:6 Hole;# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % ®RGAN\G. ZrG 1ND't I.oAM -7,5`(1't'W�Z ANCr2.5-t.7/4 cobble, DEEP OB..... lConsistengy.SERVATION HOLE Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(m) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. 0 *Nal LOAM- ,eo-(Pi`� t 6,AHb-C gt 6-!r— �1 ^� E 2.5Y��r, 20�o cobhta5 `--� Vo.y'\Ab tA' c\A law. DEEP OBSI;R ATION IIO .E 1JOG 1 tole# Depth from Soil Horizon Soil Texture Soil Color Soil �=ture,Other Surface(in.) (USDA) (Munsell) Mottling Stones,Boulderes. % DEEP OBSERVATION HOLE LOG Hvle# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(m.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % XX:::::x:::: DEED Ol3SER*VATIOPrT IILE IJOC Hole Depth 1.from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Town of Barnstable P# L 8k ,fco Department of Health,Safety,and Environmental Services UGC— 301, *16-y214 Public Health Division Date t iG -7 7 367 Main Street,Hyannis MA 02601 Date Scheduled f — 1/„ Z 7 Time JO, od Fee Pd. /6U Soil Suitability Assessment oY Sewage Disposal Performed By: �4N (�J/t} ,/� �R�`^1N E IqQ( "Wi ssed By: 'DV N N19f' L :CATIOlr1 & I;NERAI,;Ii'�1FdIA 't0N .... Location Address 075 Owner's Name 1�I �'71 CrE x.e,-,AU_ T —r). GV .�'LN . Address Assessor's Map/Parcel: l`7`I Engineer's Name'PbwN CA — C^4_1N�&R-1N lr NEW CONSTRUCTION REPAIR Telephone# -7G2'(LI*L I Land Use `/'&C-4,r-7— Slopes(%) DP ;p Surface Stones Distances from: Open Water Body T /�. ft Possible Wet Area !\ ft Drinking Water Well _26 Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) vl LE y OD 5 fV1 N r J. �o' ra'7H2. N5 I sy.2-7 t Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater "A tyd wAT&-rL- DETl1NNATt011 FDtt SEASUNA ,HIH'VVATI±� TALE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PER+COLATICJ�li TEST oats Time Observation 0 Hole# Time at 9" 1' 05- Depth of Perc 5 o Time at 6" 3 ` Start Pre-soak Time @ Time(9"-6") t' End Pre-soak Rate Min./InchG 2- Site Suitability Assessment: Site Passed�� Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--��► Copy: Applicant OBSERVATION IIO I� I,OG Holes# . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(m.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % 73 l,,5 10`� .. DEEP OBSERVATION HOLE LAG Hole#..... :: Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % lye 3- 'ra 117-0 bE>JP OB. ERVATIO OLE LO o e Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(m.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % ell DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % 1 ... . DEEP OBERVATION HE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Town of Barnstable P# p 9, !or V� Department of Health,Safety,and Environmental Services D::c—z0b# qG—TL3 Public Health Division Date 367 Main Street,Hyannis MA 02601 1 6 �.�-7 . 1 S wuvareSM °rE KAM 16 Date Scheduled I _ U e-°1-7 Time Fee Pd. 2 Soil Suitability Assessment for Sewage Disposal Performed By: -PAr-N 03-t LA (W W 9 O►M PWN)itnessed By: eJ eYgVr .. LOCATION& GENERA)� 'INFOtt1VIATt(Jt Location Address 1 .,.r- Owner's Name 7rL '7 I ! ,-P-PIA w )L-) W. LN . Address Assessor's Map/Parcel: 1-T-1 Engineer's Name"WV0J G/�t'C- 6N(s-1,Jai 1IJ� NEW CONSTRUCTION V REPAIR Telephone# -367- W 6 H Land Use Vf&f�NJ_ Slopes(%) O—S Surface Stones `^J Distances from: Open Water Body _ft Possible Wet Area X ft Drinking Water Well /�ft _ Drainage Way_��ft Property Line ft Other R ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) izvIcE 17o ,g5 r M QD a= 0 rA TF1 0/7# y 0. Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face.-��_� Estimated Seasonal High Groundwater �// Ia N0 v w/}J C� -- 'FpV N't> bET I2I NATlaI FOTt SEASUI A ,HYGH'WAT R TA LE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCCILATI( l� TEST Hate 't (1� Timed Observation Hole# I �F Time at 9" Depth of Perc '�� '1� Time at 6" � Start Pre-soak Time @ Time(9"-V) 3 1 o0 End Pre-soak Rate Min./Inch G.2.MtN/IN / Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) tN Original: Public Health Division Observation Hole Data To Be Completed on Back—� Copy: Applicant DEEP dBSEI2`�ATION HOLE LOG Hole`# .'" ' Depth from Soil Horizon •Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. stena. ,�^^ o 3� -IeO 2 M���s� ,� %V DEEP OBSERVATION HOLE LOrG' 1. Holy# . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. / ,( o J� DEE1� OBSERVATION HOLE LOG bole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % DEEP OBSERVATIOIti HOLE L( G Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % { i DEEP bl3SER"TI+DN HOLE LOC Dole# . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % I Town of Barnstable P# P a,g y Department of Health,Safety,and Environmental Services �)Ca job#:96"4 2-7— Public Health Division Date I—16 -`-7 367 Main Street,Hyannis MA 02601 S BAWWAsr$,MAIK t 0r ►�� Date Scheduled — Time 0 Fee Pd. -;;_p O Soil Suitability Assessment for Sewage Disposal Performed By: —l:^N 103^L1Af 40� *t ) L4R—_— +) Witnessed By: Zy^-qu-f 'D\jNN lAf6 - L ,CATION&GENE AL R 'dl�ORIVtAT1ON Location Address ©T-?j Owner's NameG��G� 'Pfz-crr�iZ'T1 ES �uU Address Assessor's Map/Parcel: _7�I _ Engineer's Name -1>0—N C J9 06_ I// NEW CONSTRUCTION REPAIR Telephone 36'L�j�jy1 Land Use V/t-LA Slopes(%) S Surface Stones geLl Distances from: Open Water Body T ft Possible Wet Area ft Drinking Water Well ->,/, ft Drainage Way_ ft Property Line e ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) r Lar 3 M V 77+-/— Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETIJNAT)COlri 'OYt SEASONAL HYH'VVATEt 'TAf 3LE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ 1'ERCOLATIOI TEST Date t 16 1T,atc Observation t Hole# 71-4 Time at 9" 11 Depth of Perc Lis Time at 6" Start Pre-soak Time @ v '©O Time(9%6") End Pre-soak , 1 Rate Min./inch L" 2' A\N1 IN Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-� Copy: Applicant DEEP OBSERVATION: IIOLE IL:OG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. 0 ®_'Z. C7 O(ZGANA(- to-If, 5/0 ,y- 12o'' G 1. 'A�'A� 5 Y 7M DEEP OBERVATION HOLE LOG Hole# •� Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % CAM,M, G T1+'J._ ex G'L 137- 'i DELI' OBSERYVATIUN ITOt,E�.003Cole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % DEEP OESERVATION H(J►LE LEG Hale# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % DEED O$SERV. TION HOLE LOO Hole;# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1917 SERVICE RD.WEST BARNSTABLE, MA 02668 M194 P108 L6 Name of Owner ANITA ST.ARMOND Date of Inspection: 6/17/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310.CMR 15.303.The basis for this determination is Identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. - X Liquid depth in cesspool is less than 6".below invert or available volume is less than 1/2 day flow, _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Il. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, _ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No - X. the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further Information. 1 revised 9/2198 Page 4 of 11 r t- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1917 SERVICE RD.WEST BARNSTABLE, MA 02668 M194 P108 L6 Name of Owner: ANITA ST.ARMOND Date of Inspection: 6/17/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X - Pumping information was provided by the owner,occupant,or Board of Health. X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X - As built plans have been obtained and examined.Note if they are not available with N/A. X - The facility or dwelling was inspected for signs of sewage back-up. X - The system does not receive non-sanitary or industrial waste flow. X - The site was inspected for signs of breakout. X - All system components,excluding the Soil Absorption System,have been located on the site. X - The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X - Existing information,For example,Plan at B4O,H, X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/J98 9 o Page SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1917 SERVICE RD.WEST BARNSTABLE, MA 02668 M194 P108 L6 Name of Owner ANITA ST.ARMOND Date of Inspection: 6117100 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:1 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X Septic tankldistribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n1a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1984 Sewage odors detected when arriving at the site:(yes or no): NO revised 912/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1917 SERVICE RD.WEST BARNSTABLE, MA 02668 M194 P108 L6 Name of Owner ANITA ST.ARMOND Date of Inspection: 6/17100 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of Joints,venting,evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'•10"" Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness: 8" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1917 SERVICE RD.WEST BARNSTABLE, MA 02668 M194 P108 L6 Name of Owner ANITA ST.ARMOND Date of Inspection: 6/17/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,Inspection) ;locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet Invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No):. NO Alarms in working order(Yes or No)' NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) BLE Property Address: 1917 SERVICE RD.WEST BARNSTA , MA 02668 M194 13108 L6 Name of Owner ANITA ST.ARMOND Date of Inspection: 6/17/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If:not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6 leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Aftemative system: n/a Name of Technology: n/a Comments: (nole condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 2'OF WATER IN IT AT THE TIME OF THE INSPECTION.THE SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: _ (locate on site plan) eft Number and configuration: n/a. Dept;-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level.of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: nla Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a I revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1917 SERVICE RD.WEST BARNSTABLE, MA 02668 M194 P108 L6 Name of Owner ANITA ST.ARMOND Date of Inspection: 5/17/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) a IA g c a �s N� AC 7a� � 33 gc revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1917 SERVICE RD.WEST BARNSTABLE, MA 02668 M194 P108 L6 Name of Owner ANITA ST.ARMOND Date of Inspection: 5/17/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health Checked FEMA Maps _ Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) GROUNDWATER IS AT 12+FEET FROM MAPS AND CHARTS revised 9/2/98 Page 11 of 11 No.�? .....�. � FE a................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �6 .....`® ........................OF..... ...... R Appliration for Dhip sal Works Tonfitrurtion Frratit Application is hereby made for a Permit to Construct .( %_�or Repair ( ) an Individual Sewage Disposal System at: ............kA . o -c ?�� ---------�`-" --............--•- --------------------•--.................. Location-Address r �.m ....... ..,.......... -..... ....................................... \' Owner A dress W Y , Installer Address Type of Building Size Lot_ 3 SD....Sq. feet U Dwelling—No. of Bedrooms...........3.............................Expansion Attic AJQ Garbage Grinder Q aOther—Type of Building ............................ No. of persons Showers ( ) — Cafeteria ( ) WOther fixtures .--•-••......•• -•-••••--•-•-•••--•••••-••-•--••-•-••.......•-•-••-•-••.......•-•-•------•-•••••••-•-...-•--•.....-•••-••..........-•.............••- W Design Flow.................. Q................gallons per person per day. Total daily flow.....0........................gallons. WSeptic Tank—Liquid capacitA ..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length...._............... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosinank ( ) '"' Percolation Test Results Performed by...._....SJ�)?o . ........) ............... Date... �:"�-11.J�._............ .. aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ pr ••••••••••••••••••-••---......•-••••••••••••-•••............................... .. O Description of Soil.......0. ......uia .....�-n4?.No...... U ------------------------------�\° e ..Q.1.cl.------.. ..._.. ------� ..---u-....................-------------- w .............................................................-••-•••--•-••••--••••••-•-••-•••-•••••---•--•••••---•-.•....•••-••••••--•-•-•••-•-•--••••-•••-••••••-•••-•-•-••..............-••--•--•••••- UNature of Repairs or Alterations—Answer when applicable._............................................................................................. ---------------------------------------•---------------------------------._....-----...........-•----••-•----...-------------•----------------------....---------................_......-••--.......-•-- Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of Health. igned-•>. E}�!Y!( s:--vi_ 0'1 - Application APP ... - P --•----------- Date Application Disapprove for following reasons:-•••--•••---••-•••-••--••••--•-•--•••-•--••--•-•-••••--•••-•.....••••-•••••-•-•-••-••••..................•..... ........................................ ........_.....__.... .......•--••••••-•--•••---•------•----•------------•-••........................•. ----•----... ............ Date PermitNo....................................................... Issued....................................7................. Date N04.. ._ FED.:................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... .......o .�. .......... ..OF..... Appliration for Uiipooal Workii Tonitrurtion Pumit Application is hereby made for a Permit to Construct ( k__�or Repair ( ) an Individual Sewage Disposal System at: C_ . ......... �,, \ Location-Address p-r Itot No. .V.e............. _ .......................... ........ �_ : L•( .................... . ......-•--......._...... \ , Owner Address ?.....----•-".�?�,.:Q_S.a- ---------------------------- ------- `.e.'....-1 L""------...........----------------....... Installer Address Q Type of Building Size Lot.4 .5�00____Sq. feet U Dwelling—No. of Bedrooms............J.............................Expansion Attic 00 Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .-----•----•---••----------••-•--------------- ........................................................ W Design Flow...................��Q._..........__.gallons per person per day. Total daily flow.._.. ...S..`�__._______..._.___...._.gallons. WSeptic Tank—Liquid capacitAMP..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing_ ank '" Percolation Test Results Per by.. _4�-M .._.�1._.....J`'`� -�'............... Date.. :� ...�...._.......... W Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•--------------------"---"-•--...............-----..........................-----•.............-••--•••-•-•--------•••--•-•-•--•---••......•••--...-•-- ODescription of Soil-----0 ......... � ------------------•------------------•------•----.....•--------•--••. U W ---------------------------------•-----•--••--•-•-•--••------•---•-•-•-•-..._..-•-•-------••-•-••----•-•---•--••-•--•-•-----------------••--......................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•-""----"-------------"--...--------------------------------------------------•-•-........•-_-----••--•-•-•-...•-•----••••••-------•-----•-----•-•-•---••---•-•--•-..._--•••-•---•-•-•-....._•---•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of Health. r igne •..v�.d... _................................... = ............. Application APP>r4yed Y... ....•••- ---------------- ........... _�/ Date Application Disapprove f or/t' f ollowing reasons:...............................=................................................................................. ............................. .. -•--------------------------------.............._....--•••--...-•-•--••-------------•---••-•-•-•--•--•------•--•••••--=-------•••------•----•---•••--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a .! .....� ....................................... n..........OF........... C ; (\- . . : — Tatifiratr of Toutphatt r THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (V-")' or Repaired ( ) by....... ............ -----..:- ------------ ---------------------------------------- ------ ............................................... J',p A Installer •� •-- ------------ has been installed in accordance with the provisions of TIC 5 f e State Sanitary Cod as ,es, '- ed in the application for Disposal Works Construction Permit No... .................. dated_!........................................ THE ISSUANCE33F THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL U N SATISFACTORY. 7 DATE.................... .•----.......-- Inspector..... -• •-•-•---•---••---•----------......__•••-.._..._.....-----................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .l.,�. 7 e.... OF...........- C�. . �..�ts�l�l,s-.~ Q a d1 � . No......................... FEE. _......_............. 3�io�roottl orko�=ion #rnr#Uari rrntt# Permission is hereby granted_......\J_e �- ....___._....___1 .`5 --- to Construct ( � or Repair ( ) an Individual.. Sewage Disposal System atNo..... .......\•---•......-. ............ .......................................................... -'�-�•... Street as shown on the appli tion for Disposal Works Construction Permit No.... ....�.._ Dated.......................................... .............................. ........._........_.__.._ ....._............._......._.........._. DATE. �. ..l... ...� Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON INGLe FAMIt_Y - gc- 0 Q 0 0 m IJ.o GAttBAGE (a¢�NDE2 sC� ��/✓ �� I 1 o x 6SPT%0 TAQK n 330x15o% : A 6.P , uSGr- l000 ' o,ISPoSAI PIT v6E Ioo0 6AL.-3. STC5t45- 14-52. �goTToy A2,�.Q . ll3s,� X a•B.3 = q3 G.��. k • .I • •'' enZH ' MCHARJ .� �Y.,•� /� AIAN �� •�i• ��. ��,r i� W J c� CARTER •1 C rJo.2.U4s ,. •I� JoNEs F• O No. 251U0 TE6%T Pzgm FCS144- �Y�Y -TOP FN�` N�a Idp ak,/44 �� )0w^T i 1215 ►oou INv• CO, DIST. J C,&L, 55• 0u�c �I,,//N,�� s7PT1G GZ/4..� 1000 �(• /'r'� "TANK LP p , I,,,EAGII PI IV. INV. T N ' WITIA WAco11GD Sl4lJp 6TuN6 ol /32 CE2•TIPIGD PLOT PLAN! P 2 U F 1 L L o C A-r_►o N �L= �o. .SCA LE SGALC-. /-� • �AT� /JZ$��cl A !! ` GE ctT FY THAT 'rNE �x1gr11'1 Fi*L�SKoWN N�R.FxO N C0MPL`(5 YJITN•T NE S► IDELIW �p y- P•IJ D S E'r�D►G K f2.6 Q J►R.E M 6 N T> o f 't N E- �G.�lis/ ��,�.TA/�'1cS�✓�I y/T,� -ro W N, p F �AP.P(✓'� ' A N I I.OG p.T E D •W lT N 11J 'T�}N•'6 G L o o D rP L v.I N �A 7',�_,� •SEi�T�/�3.� { DAT��3 X^a G ���11� - i3AXTEQ.a WYE INC. EQ6�'►.A►I D S u izv E`(Ot�S -T►lIS PLQti I S Na' 4N5c o o►d AN osTE2VIl.L� • M,/Ass• // i 11J,5•T'K,u M E NT 5 u Qv i`( � 'T NE 01:F•S E-r'S 6uout3> ��,�t�CS�F-• .��',/��7 o � 'U EDTo pETEW^I►.1rc �.c-r �_ INES APPLIEA►-rT' - • -- r f . 1 o Ilk , ' W��' Fi1CFiAF3D -;r, o� ALAN 'G BAXTER r� �1 aim- - ^d •�%