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Home My WebLink About0071 SPRUCE STREET - Health 71 SPRUCE STREET, " j A=216-020 a QC - �. n $ " .� Qo 14SSF.SSOit'S MAP* INSTAL I_-ER' tdA &p {31dE £} SEPTZG TANK CAPAd LEAC�IIl�GFA�'� } 'NO.i3PBEI)Mus �tJIII:}FR OR O��tlER - PERI TDATE Clobff ; iNC 'DAT $eparauoa Distance ge cen-t c 1?eeY MaxtumAdjusterl"Wua�vvrTableto fire Bottom of Le�cfiengFacity aus t Pnti►at �ftater 5npply`Wdelt aidLeng l± E Y oil,site or,witfiii[ fl feet trf learn stg fsc ty) Edge of V�letlaad and Leaohu g fap' ty tFf anY wcf lands a"st wiEhlst 3Qt}feet €teaching ficxlitY} l G v Furiushed by: —� Wei / 6 S � ti TOWN f. F BARNSTABLE P LOCATION (A SEWAGE # VILLAGE Z ASSESSOR'S PT — �"" —1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C - • s a G C A as C ABW m nb 63 p o . m •. • m � , C3 c OFFICIAL -- ra Certified Mail Fee f� 191,A Extra Services&Fees(check bar,add lee as appropnate)e' te7 d El Return Receipt(hardcopy) $ rY 4?";; •°'°' 0 ❑Return Receipt(electronic) $ ��".P --`�v"(" { AN r ❑Certified Mail Restricted Delivery $ !�",�A1 Here O ❑Adult Signature Required $ ❑Adult Signature Restricted Delivery$ O Postage US? Total Postal GOODE, THOMAS F & CARLAA Ln 9entT° 71 SPRUCE STREET o SNieeiandAi WEST BARNSTABLE, MA02668 r%- City Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail •A unique identifier for your mailplece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this r. delivery. USPS®-postmarked Certified Mail receipt to the-� •A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service' Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or'' to the addressee's authorized agent. Important Reminders: Adult signature service,which requires the ■You may purchase Certifier)Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which •Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. r and provides delivery to the addressee specified 11 ■Insurance coverage is notayailable'for purchase by name,or to the addressee's authorized agent". with Certified Mail service.However,the purchase (not available at retail). of Certified Mall service does not change the ■To ensure that your Certified Mail receipt is Insurance coverage automatically included with accepted as legal proof of mailing,it should bear a, certain Priority Mail items. i USPS postmark.If you would like a postmark on ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailptece;you may request Certified Mail item at a Post Office'"for the following services: postmarking.If you don't need a postmark on thls -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domesfic Return Receipt attach PS Form 3811 to your mallpiece; INIPOItTAM.Save this receipt for your records: Ps Form 3800,April 2o15(Reverse)PSN 7s3o-m-oo0-9a47 , 7Atfttach ems 1,2,and 3. A. Signature ame and address on the reverse X ❑Agent can return the card to you. ❑Addressee card to the back of the mailpiece, B• Received by(Printed Name) C. Date of Delivery ont if space permits. 1.r D. is delivery address different from item 17 ❑Yes If YES,enter delivery address below: ❑No GOODE, THOMAS F& CARLAA —71 SPRUCE STREET WEST BARNSTABLE, MA 02668 II I BIII�I I�I)I�I I II II II I I I IIIII I II I I I I I I II�II 3. Service Type ❑Priority Mail Express® ❑Adult Signature ❑Registered MaIIT'" ❑ du@ Signature Restricted Delivery ❑Registered Mall Restricted I Certified Mail® euvery 9590 9402 1933 6123.1776 09 c tiled Mail Restricted Delivery etum Receipt for ❑Collect on Delivery Merchandise n r u --Delive Restricted Delivery ❑Signature Confirmation^" 2. Article Number(Transfer from serviceJaben W1 very ry ❑Signature Confirmation 7 015 1730 0001 4988 0 343 r ail Restricted Delivery Restricted Delivery PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt I USPS TRACKING# First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9402 1933 6123 1776 09 United States •Sender: Please print your name,address,and ZIP+4®in this box• Postal Service Town of Barnstable ` Health Division 200 Main Street I Hyannis, MA 02601 I � I I I I I I �7 Town of Barnstable Barn OF THE T Regulatory Services Department j efica j _ BARNgrABLE; ' I &MAM 6 9. r Public Health Division i63 6�0 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0343 May 22, 2018 GOODE, THOMAS F & CARLA A .71 SPRUCE STREET WEST BARNSTABLE, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 71 Spruce Street, West Barnstable,MA, was last inspected on 2/23/2016, by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system.showed that the system"Fails" under the guidelines of the 1995 TITLE 5. (310 CMR 15.303) due to the following: • Leaching pit is holding 12"of water at inspection,with stain lines above inlet invert and into riser. You were originally ordered to repair or replace the septic system before April 20, 2018; however, this system was not repaired or replaced as ordered. You are ordered to repair or replace the system within 6..months from the date you receive this notification. Failure to repair/replace the septic system within 6 months will result in scheduling this issue before the Board of Health at a public meeting. ER OF THE BOARD OF HEALTH Thoma e , R.S. CHO Agent of the.Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\71 Spruce St W.Bam Apr2016- Second Notice.doc THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) m A � DATA OF t"E r�M,�, Town of Barnstable ' /` ''y{• U.S.POSTAGE>>PITNEY eOWES { O Public Health Division •;t /��Q, e - RARNSTARLE. ` �'''IV MASS. 200 Main Street - • o •�s 94iprEO MPS°0�' Hyannis,MA 02601 •�:• ZIP 0260 ooV.b"/ 0 " *" Y 02 4VN ++� 0000336455 MAY. 23. 2018: 7015 1730 0001, 4988 0343 LRet d Noticeumed _"�--- GOODE, THOMAS F & CARLAA 71 SCE STREET --' RETURN TO SENDERNOT 0-EL1VERAELE. 1� UNABLE TO FOP''F1ARD 61 8l � +3.3260100866'�5 �'68 3C: 02601.400200 *0269-e8211-23- 44 - .. . � 1e111��1�lsl�lci��l9�,�►��11��11�`,�i,��,�,i��,,,a��,� _� ,iiip� 1 — — - •� - -.- - T n..it - ... .. . m .. • 0 Q' Certified Mail Fee Ir $ Extra Services&Fees(check box,add tee as appropriate) r—I ❑Return Receipt(hardcopy) . $_- 0 []Return Receipt(electronic) $ -f ��-Postnnark. C3 [:]Certified Mail Restricted Delivery $ S Here C3 ❑Adult Signature Required $ ❑Adult Signature Restricted Delivery$ 0 Postage yNN 'r Iti $ Total Postage and Fees $ a Thomas F. & Carla A. Go e �_ ' o -- 71 Spruce Street West Barnstable MA 02668 Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or atterTpted --return receipt for no additional fee,present this Z delivery. USES®-postmarked Certified Mail receipt to th J ■A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service'" Restricted delivery service,which provides -r- for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent. Important Reminders. Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which ■Certified Mail service is not available for _requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified 1 ■Insurance coverage is notavallable for purchase by name,or to the addressee's authorized agent-- with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark If you would like a postmark on,' o For an additional fee,and with a proper this Certified Mail receipt,please present your -^2 endorsement on the matlpiece,you may request Certified Mail item at a Post Office—for the following services: postmarking.If you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion. of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply , F_, You can request a hardcopy return receipt or an_ .appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt complete PS Form 3811,Domestic Return Receipt,•attach PS Form 3811 to your mailptece; IMPORTANT.Save this receipt for your records. PS Form 38009 April 2015(Reverse)PSN 7530-02-0009047 SECTIONSENDER: COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverse X !! vent so that we can return the card to you. ,4diiressee Received b Printed amef- C. Var'f -R ive ■ Attach this card to the back of the mailpiece, A/��-�n,, y ry or on the front if space permits. C/'C �'�*)� 1. Article Addressed to'.4 ___ _____ _ _ D. Is delivery address different frorrl�te�rXtd? e� : If YES,enter delivery addresslbe ow: ❑No Thomas F. & Carla A. Goode ., ✓�Q� 71 Spruce Street West.Barnstable MA 02668 3. Service Type ❑Priority Mail Express® III IIIIII IIII 111111111111111111111111111111111 O Adult Signature ❑Registered MaiIrM ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted. ❑Certified Mail® Delivery 9590 9403 0922 5223 8280 04 ❑Certified Mail Restricted Delivery ❑Return Receipt for ❑Collect on Delivery Merchandise 2. Article Number(Transfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature Confirm +ationT Insured Mail ❑Signature Confirmation f 14803 ��- Insured Mail Restricted Delivery Restricted Delivery. 7 015 17 3 0110 0'01 s 4;9 9 D (over$500) PS Form 3811,July2015 PSN 7530-02-000-9053 Domestic Return Receipt 1 USPS TRACKING# First-Class Mail Postage&Fees Paid USPS Permit No.G-10 A.. 9590 9403 0922 5223 8280 04 United States 'Sender:Please print your name,'address,and ZIP+4®in this box* j Postal Service Town of Barnstable Public Health Division I 200 Main Street Hyannis, MA 02601 Town of Barnstable Barn Regulatory Services Department j * 0 STAB . D. 639 Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7015 1730 0001 4990 4803 Apr 20 2016 Thomas F & Carla A. Goode 71 Spruce Street West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 71 Spruce Street, West Barnstable,MA, was last inspected on 2/23/2016, by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.303) due to the following: Leach pit was holding 12"of water at inspection with stain lines above inlet invert and into riser. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. You may request a hearing before the Board of Health if written petition requesting same is received within 10 days. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH T o cKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\71 Spruce St W.Bam Apr2016.doc I Town of Barnstable L►suvsr�uG + . Regulatory Services D.epartinent' • � i639• ��b8 prFD ylA'I Public Health DIVIR'On 200 Main Street;Hyannis MA 02601 Office: 508-8624644 Richard Scab,Director FAX 508-790-6304 Thomas A McKean,CHO Feb 6,2007 ' Rev. 7/6/15 DEADLINES TO REPAIR'FA.ILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑ Static liquid level in'the distribution box above outlet invert due to an overloaded or clogged SAS or.cesspool ❑Any portion of the SAS, cesspool, or privy,below high groundwater elevation ❑A iy portion of-the cesspool withiri'a Zone 1 to"a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water.quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool , ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) OTHER ❑ J 10 ��r�e�I e f Repair deadline: WSEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc Parcel Detail Page 1 of 3 B.AIt.l1S"E,.61.1f= a 1 �.-, e Logged In As: Parcel Detail Tuesday, ela(ITuesday,April 19 2016 Parcel Lookup Parcellnfo Parcel ID216-020 � I DevelopotLOT7 Location 71 SPRUCE STREET Pri Frontage 1'140 �f Sec Road IRIDGE ROAD Sec Frontage,12�6�------Y Village jWEST BARNSTABLE � �) Fire District W BARNSTABLE ....... ., s Town sewer exists at this address jN0 gym) Road Index;1519 �I Asbuilt Septic Scan: Interactive 216020_1 Maps Owner Info---- Owner fGOODE,THOMAS F&CARLA A m++I Co-owner streetl 471 SPRUCE STREET street2 city,WEST BARNSTABLE state:FM—Aj Zip 02668 country I� Land Info Acres10.43 _ I use Single Fam MDL-01 A zoning IRF—1 Nghbd 0�106 .I Topography,Level Road Paved ) Utilities iGas,Well,Septic Location Construction Info Building 1 of 1 Year 19 55 I Roof Gable/Hi Ext'� 700 Shi Built struct pI wall Wood Shingle Living 31 fi8— � � Roof s h/F GIs/Cm AC jNone � Area Cover �� p � Type Int Bed ' '" 7-W� Style!CapeCodi wall Typical � Rooms,2 Bedrooms �� ;Residential ) Floor Model 1Carp�� Batn 1j'Full 0 Rooms Half m Grade AverageI Type HOt Air .n .� Rooms5 Rooms e 2, � stories 1 1/2 Stories _.I Heat�Oir" "" "" `— I Found Poured Conc. I Fuel ation Gross[ 520 Area • Permit History Issue Date Purpose Permit# Amount Insp Date Comments http:i/issgl2/intranet/propdata/ParceiDetail.aspx?ID=15385 4/19/2016 fI j�0-20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 Spruce St Property Address Thomas Goode Owner Owner's Name �! information is Barnstable �� MA 02630 2-23-16 required far every �+ page. City/Town State Zip Code Date of Inspection 1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: . , ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further EyAaatgo y cal Approving Authority 2-23-16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �0 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Spruce St Property Address r Thomas Goode Owner*, Owner's Name information.fo is Barnstable MA 02630 2-23-16 requireii�for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable MA 02630 2-23-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety orthe environment. 1. System will pas's unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts ' . Title 5 Official Inspection Form Subsurface Sewage Disposal System,Foam -Not for Vol u ntary,Assessments qM 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable MA 02630 2-23-16 page. City/Town ' State Zip Code Date of Inspection B. Certification (cost.) 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: S D) System Failure Criteria Applicable to All Systems: You must indicate`.`.Yes"or"No', to each of the following for all inspections: Yes No r ® ❑ 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 El ® 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 a ❑ ® than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is Barnstable MA 02630 2-23-16 required for every ' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion'of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool.or,privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis - and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of.10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes» or"non to each of the following, in addition to the questions in Section D.. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ ,the,system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins^3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable r MA 02630 2-23-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes. .. No ❑ ® Pumping information was provided by the owner; occupant, or Board of Health E ® 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 X ' this inspection? Were as built plans of the system obtained and examined? (If they were not El ® • available note as N/A) _ ® ❑ ,Was the facility•or dwelling inspected for signs of sewage back up? t.. ® ❑ •Was the site,inspected for signs of break out? f r , ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, • ,_ dimensions, depth of liquid, depth of 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 s 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 ♦ F ,Residential Flow Conditions: Number of bedrooms (design): . 2. Number of bedrooms(actual): 2 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 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 •�� 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required fer every Barnstable MA 02630 2-23-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Well 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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-3113 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 71 Spruce St M Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable ' '" MA 02630 2-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ' Source of information: N/A 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:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . wM 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable MA 02630 2-23=16 Page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): - Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): , Distance from private water supply well or suction line: feet Comments (on condition of joints, venting,evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth:. 12" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Spruce St Property Address Thomas Goode ,• Owner Owner's Name information is required for every Barnstable MA 02630 2-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ Septic Tank (cont.) • . . Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee-or baffle 1 Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable MA 02630 2-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: 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.): i *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 f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable MA 02630 2-23-16 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)_(locate on site plan):' . . • L. Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑. Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): li * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable MA 02630 2-23-16 page_ City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: 1-1000 gal ❑ 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.): Leach pit was holding 12" of water at inspection with stain lines above inlet invert and into riser. 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 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable MA 02630 2-23-16 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 M 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable MA 02630 2-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �r el t5ins•3113 Title 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 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable . MA 02630 2-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Site Exam: ' ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Spruce St Property Address Thomas Goode Owner Owner's Name information is required for every Barnstable MA 02630 2-23-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No.._,f ---- � •`' � P :�E1' Fee-----T_'/ -------- BOARD OF HEALTH TOWN OF BARNSTABLE lication rVell Construction �� .�o hermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair *'Tan individual Well at: Location Address Assessors Map and Parcel - �/ Owner / ^ /�ddress Installer — Driller Address Type of Buil welli'ng - ----------------------------------------------- Other - Type of Building---______—_____________ No. of Persons----------------- Type of Well— �it�s��E -- ---- Capacity---— - - --——--- -- Purpose of Well ---- — ---- ------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed- -- -- -------- --�f✓ �� ®dale Application Approved By-� date Application Disapproved for the following reasons: —------ - ------------- — --- ----- ----------------------------------------------------------------- ,Z�q — date Permit No. Issued --°'�' __ �_—_ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (� by------ ��'�/��_�__�Q�/�/cif/Q--------------------------------------------- /�IInsstiller has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit�� '0�—��— Dated� � � THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- __ Inspector-----------------__._ t No.-/= -=- � "' Fee--- - '-------- BOARD OF HEALTH TOWN OF BARN-STABLE ZippCicationArle[C Conotruct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (Van individual Well at: ----------7 --S . u '_sf--- if Location` .Address Assessors Map and Parcel / _ - f Owner Address -------- -�------�- --------- Installer Driller Address Type of Building /1-1 welling----- L----------------------------------------------- Other - T e of Buildin No. of`Rersons------------------------ ----_-______ YP / g --,- -- --- Type of Well-- � �'?d��-------- ---- _ 1 -=- ----- ---YP --1 @apacity=----------- Pur -ose of Well ----— - -- ---- Agreement: The undersigned agrees to install the aforedescribed individ, al well-ih accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection--Regulation - The-undersigned further agrees not to place the,, 'e ii3'�p�er�ai, nn until a Certificate of Compliance has been issued by the Board of Health. \\� Signed ---f��.��d0 l daEe -- Application Approved By�L�d �� ' it date Application Disapproved for the following reasons: -------- ------------------------=-----__—_— date Permit No. � — Issued J ``-' '� —- date « ..f«Yli.i.#«if♦t�i#i«#«il.�il142i�#fififYT►l4Ti!!i!.I!•i.0'{l3Yil!)itaCafi4bx3ySfd4itCf82tS.i4#!43ilifiY#4iS#wiTiT►.T#S4'�3ti9iTiai ff9i!iV3i'�isivif3f'.d#isis�i'3.YR i3a�3>3t;a.:l:��>`: BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (/) by----- — -- Ins4ller Ze) at--=--has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation.as described in the application for Well Construction PermiA46.AVA94Lf Datedz� -_e - 4;:�- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- --- Inspector-- --- - - - ------------ afri.«ea#i+fe««#rYe#s#a«fifaeis.»rxisa:ixiez�#xzseie#esix�irioa4rsiAiaa�axasfw6siasaieirowasnessis�wasaxifafifiv�firir�.�iai�ia.#axa<avifa.ra.afae..atier«r.Y+s�..taf4xayaf�,�,.v� BOARD OF HEALTH TOWN OF BARNSTABLE Yell Construct ion Permit 06 Fee Permission is hereby granted .�Civ' `' �� Q,��✓,/.�q to Construct ( ), Alter ( ), or Repair (fo) an Individual We11 at: ` Street t as shown on the application for a Well Construction Permit No. - �`,gajm �^°° Dated �D /li Dd Board of Health ` DATE a T,C"`�D/V T Gr,�E// COMMONWEALTH OF MASSACHUSETTS EEED EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 RNSTABARNSTA ARGEO PAUL CELLUCCI Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 71 SPRUCE ST W. BARNSTABLE MA. 02668 Name of Owner PETER HURWITz Address of Owner: Box 227 E.WALPOLE MA.02032 Date of Inspection: 9/14/00 Name of Inspector:(Please Print)JOHN GRACI o I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) fileLEIVL-0 Company Name: TITLE V INSPECTIONS S E P 2 2 2000 Mailing Address: BOX 2119 TEATICKET MA.02636 _ Telephone Number: 664-6813 'O4VN OF 8AP1NSTAaLF l ..- Ha DEPT CERTIFICATION STATEMENT } •' I certify that 1 have personally inspected the sewage disposal system at this address and that the Information reported below is true,—accurate'-- and complete as of the time of inspection.The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection Is based on criteria defined In Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further Eva on By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:9/14100 The System Inspector shall jubmit copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this Inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.RECOMMEN MOVING TREES NEAR SEPTIC TANK TO PREVENT POSSIBLE ROOT DAMAGE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02668 Owner: PETER HURWITz Date of Inspection:9/14/00 INSPECTION SUMMARY: Check A, B, C, of D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are Indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n/a One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all Instances.If"not determined",explain why not. n/e The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the Inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure Is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n& 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 ..t revised 9/2198 Page 2 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02668 Owner: PETER HURWITz Date of Inspection:9/14/00 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 WILLPASS 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: U; _ 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 nLa_(approximation not valid). 3) OTHER nla i revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02668 Owner: PETER HURWITz Date of Inspection:9/14/00 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 i,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 3AS 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 n&. 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 vrthin 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-I'-.VPA)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. revised'9/2/96 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02668 Owner: PETER HURWITz Date of Inspection:9/14/00 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, L 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) 11 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with'Information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02668 Owner: PETER HURWITz Date of Inspection:9/14/00 FLOW CONDITIONS RESIDENTIAL: Design flow:—M g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 449. Number of current residents:-1 Garbage grinder(yes or no):YES. Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no)M Seasonal use(yes or no):AM Water meter readings,if available(last two year's usage(gpd): Iva Sump Pump(yes or no): NQ Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nla Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):_10 Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:WA Last date of occupancy: Wa OTHER: (Describe) nLa Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: n/A System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nl& gallons Reason for pumping: n& TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: a/A APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 25 YEARS OLD Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02668 Owner: PETER HURWITz Date of Inspection:9/14/00 BUILDING SEWER: (Locate on site plan) , Depth below grade: U Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: n/a Diameter: nla Comments: (condition of Joints,venting,evidence of leakage,etc.) THERE IS TOWN WATER SEPTIC TANK: X (locate cn site plan) Depth below grade: fi Material,of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wit If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ n{a Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: il Distance from top of sludge to bottom of outlet tee or baffle: U Scum thickness:Z Distance from top of scum to top of outlet tee or baffle:-a Distance from bottom of scum to bottom of outlet tee or baffle: 1fi How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) `✓, SEPTIC TANK AN13 ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. .I GREASE TRAP: (locate on site plan) a Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) Wa Dimenssons: n(a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle:j/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.) nia revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02688 Owner: PETER HURWITz Date of Inspection:9/14100 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: WA Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nla Dimensions: nLa Capacity: WA gallons Design flow: Wa gallons/day Alarm present: MQ Alarm level:jVA_ Alarm in working order:Yes_No_ NO Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) tf 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.) nLS PUMP CHAMBER: MQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) nLa revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continues) Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02668 Owner: PETER HURWITz Date of Inspection:9/14/00 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: Wa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: _nLa leaching galleries,number: jVa leaching trenches,number,length: nLa leaching fields,number,dimensions: Wa overflow cesspool,number: Wa Alternative system: nLa Name of Technology: j3& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.NEVER MORE THAN 6". CESSPOOLS: _ (locate on site plan) Number and configuration: n(a Depth-top of liquid to inlet invert: n& Depth of solids layer: Wa Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n& Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9098 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02668 Owner: PETER HURWITz Date of Inspection:9/14100 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) Il/a C s, �c1c� �rC a � p AA a' a A6 a' IA 4 Qcs` .. cc revised 9/2/98 Page 10 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 SPRUCE ST W.BARNSTABLE MA.02668 Owner: PETER HURWITz Date of Inspection:9/14/00 NRCS Report name: nLa Soil Type: Wa 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) USGS MAPS AND CHARTS-12+FEET revised 9/2198 Page 11 of 11 c,r, ,