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HomeMy WebLinkAbout0280 WILLOW STREET - Health 280,Willow Street A 1'31 —'057 West.Barnstabfe . I cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �f1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s1 ` 280 Willow Street rr., V Property Address Jay Askew (7 Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every ;gage. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Em :When llling A. Inspector Information cs1* JL-11) ling out out forms on the computer, Brett Hickey ise only the tab <ey to move your Name of Inspector cursor-do not B&B Excavation ise the return Company Name <ey. 374 Route 130 c� Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. 0 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails ae��M BreX Hidq Brett Hickey 8-29-19 -:,..bae:2018.09.OJO8:L00-0aW Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t; u 280 Willow Street Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes:., . I % ❑N 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: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 280 Willow Street Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will ;pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c� Commonwealth of Massachusetts �- r Title 5 Official Inspection Form Iel Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 280 Willow Street v Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SA n Ely p S and the SAS Is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `.......... / 280 Willow Street Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ a Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form I�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 280 Willow Street u Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No R ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? R. ❑ 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) ❑ El Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? M ❑ Were all system components, excluding the SAS, located on site? El ❑ 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ El 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)] l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 280 Willow Street v Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): 330/G P D DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes Qi No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes R] No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes (E No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: ****WELL WATER**** Sump pump? ❑■ Yes ❑ No Current Last date of occupancy: Date l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �sS1, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments l; 280 Willow Street u% Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: p 9 Source of information: Owner- last pumped 2013 Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 280 Willow Street Property Address Jay Askew Owner Owner's Name information is required for every West Barnstable Ma 02668 8-29-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Leach field added 10-2-90 per permits Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): >100' from well to SAS Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 280 Willow Street i V Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11611 Depth below grade: feet Material of construction: X concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal list age:ge: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 10of Sludge depth: 2611 Distance from top of sludge to bottom of outlet tee or baffle 611 Scum thickness 411 Distance from top of scum to top of outlet tee or baffle 11of Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 280 Willow Street v Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every gage. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 I Commonwealth of Massachusetts ,p Title 5 Official Inspection Form gal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u°- 280 Willow Street Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 280 Willow Street Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: (2) leach fileds Q leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY l;� 280 Willow Street Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. System has 2 leach fields (18'x38' and 14'x34' per records provided by Board of Health). 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts i p Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. 280 Willow Street v Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 280 Willow Street Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately vxa a c XSSEssOR'S, ©r��l cAs " sE�-nc_.rwnrrc.car�ec�rx-Y.,` _ LEACHING3 CC_rry- type) 29 Sepa�raticyn T✓istance Htivvean the: YvTaxiir um Axlj sited GrcutxrIwazcr Tabla tr the at5tunn CIE,Lrzuhi Tree. 'Private Watet 5uyply Wal!and':3.aaahxng Facility, -CI3`-any wtits exist . Qn ait&'or wit n 200 feet of icaching facility) Edge::of Wetland and, ZcacY i ng`Facitity,(tf az€y,..>cttancls.czis( wrj"n 300 fret of teaching':€acility) Turni'shed,by,` 3 AA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts in ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 280 Willow Street Property Address Jay Askew Owner Owner's Name information is Test Barnstable Ma 02668 8-29-19 required for every Dage. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ■❑ Surface water ■❑ Check cellar ■❑ Shallow wells GW >4' below SAS Estimated depth to high ground water: 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) El Checked with local Board of Health -explain: see below ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Information on file at the local Board of Health was used to determine high groundwater. A test hole dug 4' below SAS showed no ground water was encountered. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts to Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 280 Willow Street Property Address Jay Askew Owner Owner's Name information is West Barnstable Ma 02668 8-29-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 �j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 280 Willow Street Property Address Katherine Murphy Owner Owner's Name info-mation is required for West Barnstable MA 02668 9/25/2013 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the conputer,use 1. Inspector: only the tab key to move your Ron Burlingame lll) cursor-do not Name of Inspector use the return key. Company Name ffi 58 Oak Street Company Address West Barnstable MA 02668 City/Town State Zip Code 508-776-8544 S 14124 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ fails ❑ Needs Further Evaluation by the Local Approving Authority 47-L -z.,,� 09/25/2013 Inspector's Signature A 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-11/10 Title 5 Official IT,.n :Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 280 Willow Street Property Address Katherine Murphy Ow-ier Owner's Name information is required for West Barnstable MA 02668 9/25/2013 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): i t5ins•11/10 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 M ,•''V 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ 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 316 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 h I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 280 Willow Street Property Address Katherine Murphy Ow-ier Owner's Name regjir dfo is West Barnstable MA 02668 9/25/2013 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary.to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system. has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow 45ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 280 Willow Street Property Address Katherine Murphy Owner Owner's Name requiratifo is West Barnstable MA 02668 9/25/2013 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10• 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 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every page. CitylTown State Zip Code Date of Inspection D. System Information Description: Septic tank, 2 D-Boxes and 2 leaching fields. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d No 9 ( Y 9 (gP ))� Detail: Well water Sump pump? ❑ Yes ® No Last date of occupancy: 09/25/2013 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every 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: 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•11/10 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 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every 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: All components installed on 1990 from as built plan. Were sewage odors detected when arriving at the site? I❑ 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.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Inlet&outlet covers on septic tank brought to grade and D-Box cover brought to grade. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is West Barnstable MA 02668 9/25/2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 4" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 2" How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date .5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every 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•11/10 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 M 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every page. Cityrrown 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 Normal 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.): Water flow was level. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): t If SAS not located, explain why: -5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 280 Willow Street Property Address Katherine Murphy Owner Owner's Name requir required is West Barnstable MA 02668 9/25/2013 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 16x36/ 14x34 ❑ 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.): 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 :51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 280 Willow Street Property Address Katherine Murphy Ow-ier Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every 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.): :5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ,•�''y 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every 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 2- 5 the S , � o t t A t \ t 1 ' 4 e � 4,�3ox 7, iaoo5�� ® SToASE r-fC4S t:5ins•11/10 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 �M 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 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: No H2O at 10 feet feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/1/1990 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 imust describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 280 Willow Street Property Address Katherine Murphy Owner Owner's Name information is required for West Barnstable MA 02668 9/25/2013 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r Commonwealth of Massachusetts OKI Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes 111 Name of Inspector saa Company Name 25 Deer Ridge Rd Company Address Mashpee MA 02649 Cityrrown State Zip Code 508.272.6433 Telephone 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/11/10 InspectoW Sign atu 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. ( I 0 f Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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: Pumping suggested every 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 Cityrrown State Zip Code Date of Inspedion B. Certification (cunt.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a 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 %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . ' 280 Willow St Property Address Bauer Owner's Flame West Barnstable MA 02668 11/11/10 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11110 CitylTown 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)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Vey 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): unknown Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): well -- Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: Septic Tank from 1974 new d-box and leach field 1990 Were sewage odors detected when arriving at the site? ❑ Yes 0 No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,." 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: >100' feet Comments(on condition of joints, venting,evidence of leakage, etc.): Septic Tank(locate on site plan): 1'6" 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: 1000g Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle '12" Scum thickness 1/2" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >211 - How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): n/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a Tight or Holding Tank tank must be pumped at time of inspection) locate on site plan): 9 9 ( P Pe P )( P ) Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): n/a Commonwealth of Massachusetts MIA Title 5 .official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �•' 280 Willcw St Property Address Bauer Owner's Name West Bamstable MA 02668 11/11/10 Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Desicn 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.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Level w/the bottom of the pipes Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No adverse conditions Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •°'Y 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 2 ❑ 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.): 2 Fields. The 1 is assumed to be original and 2nd installed 1990. No evidence of backup for either field. Commonwealth of Massachusetts ROME Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: ---- Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J" 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. J-4� VT 3R � . 3� r o'r -�ol�c— [ 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 280 Willow St Property Address Bauer Owner's Name West Barnstable MA 02668 11/11/10 City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >81 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: 2006 augered hole for Title 5 inspection on file. NGW at 8'. Bottom of SAS 4' as okc� COMMONWEALTH OF MASSACHUSETTS Z LXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m , c DEPARTMENT OF ENVIRONMENTAL PROTECTION M Y c e� pqM SVOv A350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 a5 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM VORM PART A CERTIFICATION MAP 131 PAR 057 Property Address: 280 WILLOW STREET _ WEST 13ARNSTABLE,MA 02668 3�Vzpl Owner's Name: ADAM S,DAN _ Owner's Address: PO BOX 901 _ WEST BARNSTABLE,MA 02668 _ Date of Inspection MARCH 20,2006 Name of Inspector:(please print) JAMES D.SEARS _ I Company Name: A&B Canco Mailing Address: 350 Main Street West Yar_mout_h,,`.!..,� 02673 _ ! � Telephone Number: 508=i 75-2500 _ �f-j _ CERTIFICATION STATEMENT i I certify that I have personally inspected the sewage disposal system at this address and that the information eported W " 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)EP i*7 approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: d._ Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Qzz��250-12 Date: 3-20-06 The system inspector shall submit copy of this inspection report to the Approving A,�thority(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 op d or greater,the inspector and the s�s ient owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the owner and copies sent tot he buyer;if applicable,and the approving authority. Notes and Comments WELL ON LOT, SEE PAGE 1.0_ CHECK BARNSTABLE BOARD OF HEALTH,NO LOCATION ON FILE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2900 1 I Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCH 20,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: a/ _ I have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfrltration or tank failure is irrnnirrent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCH 20,2006 C. Further Evaluation is Required by the Board of Health: N/A 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety`and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has aseptic 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 l:eet but 50 feet or more from a private water supply well". Method used to determine distance This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: �I Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCH 20,2006 D. System Failure Criteria applicable to all systems: N/A 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 leaching is less than 6"below invert or available volume is less than day flow �— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CNIR 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 is 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 1.5.304. The system owner should contact the appropriate regional office of the Department. f' Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCH 20,2006 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)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CN1R 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCH 20,2006 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): WELL WATER Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to,the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): 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) Tight tank Attach copy of the.DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCI:I 20,2006 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 1' Material of construction: if concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 3" Distance from top of sludge to the bottom of outlet tee or baffle: 27" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND 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.): MAIN TANK AT WORKING LEVEL.INLET BAFFLE,INLET COVER 18"CEMENT AT GRADE.OUTLET TEE COVER F BELOW GRADE.NO SIGN OF OVERLOADING OR LEAKAGE.; GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete _ metal fiberglass _ polyethylene other (explain): _ Dimensions: Scum thickness: Distance from top of scum to top of outlet.tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,stru.:tural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): x Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCH 20,2006 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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#1 IS 1' 16"X 16"-1'BELOW GRADE.ONE LINE IN,THREE LINES OUT.TWO LINES OUT TO OLDER FIELD,ONE LINE OUT TO NEWER FIELD.BOX#2 IS CLEAN.NO SIGN OF SOLID CARRY OVER.BOX#2 IS 18"xl6",40"BELOW GRADE.TWO LINES OUT. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 280 WILLOW STR' ET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCH 20,2006 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _ leaching chambers,number: leaching galleries,number leaching trenches,number,length 4— leaching fields,number,dimensions: 2 overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.' LEACHING IS TWO FIELDS.OLDER FIELD IS TWO PIPES, 16'x36'.NEWER FIELD IS THREE PIPES, 14'x34'. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionX locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids slayer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Page 9 of 1 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART C SYSTEM INFORMATION(continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCH 20,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. .Al 0R L✓2`L R 1` r 43 0 4 JVF v x Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' - PART C SYSTEM INFORMATION(continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: MARCH 20,2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 8 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: �— Observation site(abutting property/observation hole within 150 feet of SAS) _T 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: TEST HOLE 8' NO WATER.TEST HOLE 4 BELOW FIELD. Title 5 Inspection Form 6/15/2000 11 i COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION A 1W A( Y M sr RECEIVED L� � i 350 MAIN STREET sa WEST YARMOUTH,MA 508-775-2800 MAY 2 12003 f TOWN OF BAht<S TABLE TITLE 5 HEALTH DEFT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 131 PAR 057 Property Address: 280 WILLOW STREET �/� WEST BARNSTABLE,MA 02668 -0 I Owner's Name: ADAMS,DAN Owner's Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Date of Inspection APRIL 29,2003 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall su Yittopy 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 tot he buyer,if applicable,and the approving authority. Notes and Comments WELL ON LOT, SEE PAGE 10. CHECK BARNSTABLE BOARD OF HEALTH,NO LOCATION ON FILE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: APRIL 29,2003 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: 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: APRIL 29,2003 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to detennine 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of 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 detennine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: APRIL 29,2003 D. System Failure Criteria applicable to all systems: N/A 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 leaching is less than 6"below invert or available volume is less than day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fonn.) NO (Yes/No)The system fails. I have detennined 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS, DAN Date of Inspection: APRIL 29,2003 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping infonnation 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 nonnal 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 infonnation on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ Existing infonnation. For example,a plan at the Board of Health. ✓ Detenmined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: APRIL 29,2003 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms: 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): SEE NOTE [if yes separate inspection required] Laundry system inspected(yes or no): SEE NOTE Seasonal use(yes or no): NO Water-meter readings,if available(last 2 years usage(gpd)): WELL WATER Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped detennined? 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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: APRIL 29,2003 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: I Material of construction: ✓ concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions detenmined: ASBUILT AND 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.): MAIN TANK AT WORKING LEVEL. INLET BAFFLE,INLET COVER 18"CEMENT AT GRADE.OUTLET BAFFLE COVER F BELOW GRADE.NO SIGN OF OVERLOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: APRIL 29,2003 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(]ocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alann in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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#1 IS AN OLDER BOX, 16"x21", I' BELOW GRADE.ONE LINE IN,THREE LINES OUT.TWO LINES OUT TO OLDER FIELD,ONE LINE OUT TO NEWER FIELD.BOX#2 IS CLEAN.NO SIGN OF SOLID CARRY OVER.BOX#2 IS 18"x16",40"BELOW GRADE.TWO LINES OUT. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS,DAN Date of Inspection: APRIL 29,2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number leaching trenches,number,length ✓ leaching fields,number,dimensions: 2 overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS TWO FIELDS.OLDER FIELD IS TWO PIPES, 16'x36'.NEWER FIELD IS THREE PIPES, 14'x34'. CESSPOOLS: N/A (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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS, DAN Date of Inspection: APRIL 29,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i I c ` \ / � o ' 1471 ,I/ 1 � V11 r) t-)x ✓3�' x Title 5 Inspection Form 6/15/2000 10 I Page 1 I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 280 WILLOW STREET WEST BARNSTABLE,MA 02668 Owner: ADAMS, DAN Date of Inspection: APRIL 29,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 8 feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: J Observation site(abutting property/observation hole within 150 feet of SAS) J 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: TEST HOLE 8'NO WATER. TEST HOLE 4' BELOW FIELD. NOTE: PAGE 6,LAUNDRY NEEDS TO BE PUT BACK INTO SYSTEM: PIPE THAT IS THERE IS CAPPED OFF. LINE FROM HOUSE TO WOODS MUST BE REMOVED. r,422 i� G21 A . Title 5 Inspection Form 6/15/2000 11 TOWN OF BARNSTABLE LOCATION b%�--� 1 , S± SEWAGE AaO 1 VILLAGE ASSESSOR'S MAP 6t LOT INSTALLER'S NAME & PHONE NO. � � �+(Zli�rl. i SEPTIC, TANK CAPACITY ba LEACHING PACILITY.:(type) ' (size) 14, NO. OF BEDROOMS RIVATE WELL OR PUBLIC WATER_ BUILDER OR OWNERrJ ' DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED- VARIANCE GRANTED: Yes No `-J i W +� x , TOWN OF BARNSTABLE LOCATION LU' SEWAGEy VILLAGE11). ASSESSOR'S MAP & LOT P �' � ; INSTALLER'S NAME & PHONE NO � bao .. 1 �� SEPTIC TANK CAPACITY lboo LEACHING FACILITYAtype) (size) -a _ 14 NO. OF BEDROOMS RIVATE WELL OR �P,�UBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: � `' VARIANCE GRANTED: Yes No �G �� � ,�' �_� - �� ��� ���1� i�F3 � . "� �� �� w � -�-c� � a� FEB ._-...._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH MAP J TOWN OF BARNSTABLE PARCEL, Allp iration for Di��niia1 orkii C� a� x r#WUT rrMtT "'._._�`° Application is hereby made for a Permit to Construct ( ) or Repair ( individual Sewage Disposal System at.. ..... .\�11 ...- ` -----•---------------------- ------------- 4....�?.� 'YP.Wl `............................ Jn --Location-Address or Lot No. ...........Z .�Cf%kr. 0................. .........................-5- - e...-•---------------------------------................ Ow Address a Z Q _f .:r. .V ...._ q ........................... Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms___---_-Z...............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers � YP g ---------------------------• Pe ( )--- -Cafeteria ( ) Otherfixtures ----------•---- ---•--•--•--•--------------------•--.•-----------•------••----•----•-------•--•---•--•-•---•.....• ......•--- W Design Flow.......3.15'.7......................gallons per person per day. Total daily flow......��_'_Z•;D....._._..._......_....gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench No....._'............. Width...J._J9......... Total Length....:",..... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..........=............................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.___---_-___-__-- --. f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----------••-•----------••-•-•---••-----....--•--------------------------------------••-•-..._---- ...... .---------------------------------------------- 0 Description of Soil........................................................................................................................................................................ x (� ----------------------- ••------ ---------------- -------------------------- ---•------------ •--------------------- ----------------------- -•----------•---------------------------------------- ,W�, --------•------------------------•-----------•---------------••-------•-------------•--------•----••----•--•-•-----------------------•---•----------••-a-----------------------------------_----.------------�- V Nature of Repairs or Alterations—Answer when applicable.._. ........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed b the and of health. Si ne g ----- --- -------- ------- -------------------- ....../.e..���-.�.. to Application Approved By Ls --------------------------------------- --- ------/V ..o0 Application Disapproved for the following reasons: -----------------------------------------------------..--------....------...----------- ................ -------------------------------- -- ------------- ------------------------------. --- ----------...------------------ --------.................................................. -------_................................ ��/ Date Permit No. �� 1.. -L . Issued ------------15 ........................- e No.. ...?..yZ Fms........ ......_. THE COMMONWEALTH OF MASSACHUSETTS I f BOARD OF HEALTH TOWN OF BARNSTABLE S� Appliration for Disposal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( t.)�an' ndividual Sewage Disposal System at: ` .........r�� d.-_••9 N�&{xis.?..--••-•!�EE-•----•----------•---------- ............... _...` a W ,�,.K�4 ............................... Location-Address or Lot No. ' .... ......... ................. ..........--............. ....-- -••--••----•--•---...............-...--• •-- Owner (� �/ Address r �- a •-••-•-- .k `� ::.�..!!4_!!u�.---�� ----- r ..-----••............ ............... .t.n....-----1��)c u k-`. .. ........................ Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........3...............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons.........•................... Showers ( ) — Cafeteria ( ) Q' Other fixtures -----------•... •-••--•---••......-•••••--••-•---••-.••---------- W Design Flow........ .. .........................gallons per person per day. Total daily flow-----:73-_D�-••-•-•_----_--_---gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench-7 No. ................... Width... `....... Total Length.....'a3_----cart---•- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_._-_-_.--_._-__•.•_---- rrxq Test Pit No. 2............:..minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ----------------------------------••---------------.......-•------------..........------------...--.....--•---------............_--••-•--••---•--------....•. ODescription of Soil...............................................................................•----•---------------••-•------------........--•-•-•-----•----•--•---....._....---•------ V ..................... -••-•-...•••••••-•---•-•-----•:...-•-•-••••--•-•-•--•--•-•••-•-•...------••-•----•-•-••--•-•-----------------••...•-----•--.._...........•••••..........._..............-•••----••- x --•- . -- ---------------•-----------•-•.........-••-----•••• f U Nature of Repairs or Alterations—Answer when applicable._..----A?—A ........ ......... ( 0........"9 �— � •-1 -------------------------••-----•-•---•------------•-......---------------•-•-----•-••-•--•--•-----------------............ ,f Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Cg�nn issued b the b"oard of health. Sign ... . ..... ��. �`-�.�.. re A Plication Approved 1.BY ........ .�L�----P `�`L" .... Application Disapproved for the following reason.. .............. ................................................................................................................ --------------- ---------------------- ------/. ......------...../--L---/...---...---...--...--------...-----------------------...--------------------------------.............---- ............... ............------------------------- Permit No. ....(:.51 ...................7Issued l�' .�.q.t3............. e THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH TOWN OF BARNSTABLE (9elrttftrate of (farayltttlnre THIS IS TO CERTIFY',That^the Individual Sewage Disposal System constructed ( ) or Repaired ( by....................................-.....�. �.5 -Y ..-. -z"l�D �... ................................................................................................................................. Installer at ----------------- ---- ��--0....------...�t-�.��;\ca. 4 a........15.5:............................. ...----.��--"1N&"WA_..................................................---------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as d, d in the application for Disposal Works Construction Permit No. ... _0--"L/..�.. ..--- dated ..T�... . ....l/.(5.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARi4NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. --� DATE--------- 11----- � � ��...................................................... --- Inspector . �......... , .................. ---...........-----.--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f� TOWN OF BARNSTABLE No......................L. FEE.... ........... Disposal Narks ion' strurtiolt -ermit Permission is hereby granted----•-•-• �� � `!� n----•............................................................ to Construct ( ) or Repair ( ) ) an Individual Sewage Disposal System atNo.................'73? ...•.........`.3.t—.a-1. ,�_ ./..........5�5n...................tom ---•--•-------••-•-•--------- ................. Street � as shown on the application for Disposal Works Construction Permit No%f1=-�' �C� _ Dated../�lz _.`�d.................. - Board of ealt{trg DATE.. --12- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS J L ,�f v THE COMMONWEALTH OF MASSACHUSETTS -�( 05 BOARD OF HEALTH , r U b \ ��y�......-_OF........�jf... ... 4 .... '0. .. .......... o � - oiia Wears TontiIrurtiun autit ,���Iir�ttiuu -fur �t�� 1 k � A plication is hereby made fog a Permit to Construct (�or Re air ) an Individual Sewage Disposal Syst t 1/_e Location-AU-dress / or o. s� ... Address........... ..... ......~ ------....--•-----•-•---•----•---------._...........--•-•-............-------------••- Address QType of Buildin Size Lot____________________________Sq. feet U DwellingKNo. of Bedrooms------------------- -- -------------------Expansion Attic ( ) Garbage Grinder ( ) 0-1-1 Other—Type of Building ____________________________ No. of persons......,--------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------- - W Design Flow...................... [d..------gallons per person per day. Total daily flow___.__.........._ Q- _..gallons. WSeptic Tank t Liquid capacity llons 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.�4` ---sq. it. z Gther Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date,-------------------------------------- aTest Pit No. I................minutes per inch Depth of "Pest Pit.................... Depth to ground water....____-__-_.-._-.-.__- f�, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-.__._.----_---------- Q+' ----------------------------------- --- --••-••----- ................................. -------------•-- -- -- -------------------------- 0 Description of Soil........................... •-• ... •--•-•-- -- ---- --•n_---/�--- U ----------------------• ----------- -• -�'�G�-•-e50------ ----------------------------------------------------------- --- 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 Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in operafion.uritil a Certificate of Compliance has been is ed�by theboard f health. Signed ... ••-- ------------D-......-•--•_.... Application Approved B '��------ _ ...- PP PP Y 4,lelsl 7 - Date tr Application Disapproved for the following reasons-------------------•---- • -------•--------------------------------------------------------------- ----•-------•------••-------•-----••------------•------------------•--------------------------------......----------------•-•-•--------•--•.....----------------------------------------------------- Date PermitNo.................................._..--------•---•.--'-•• Issued........................................................ Date _ �. .- , . �. . , 2` a + . . � �: �� -- �'� � ,, . . �� L�c��' o �..�- .. '4 .... �� �� ��•� � ,:,. } . ..� J/r�, FED... . ................. THE COMMONWEALTH OF MASSACHUSETTS EOARD'�OF .HEALTH OF.... _ --------------- Application -fear Riipuiitt1 Worko Towitrurtiott Prrutit Application is hereby made fo Permit to.Construct (4ol0000r Re air ) an Individual Sewage Disposal Syst at o Location•A ress ,;� ----•- o No. �-�-Off--- .: -- -•- �'-------�T-:.._..-(k- ' • ---•- ���' ---- '- -•-- Address a --•..................•---....:. j .• •`-----•-----•---•--....----ddre--........................................... � Installer _ ,. ".:�. Address Type of Buildin `` Size Lot............................Sq. feet DwellingKNo. of Bedrooms._._-_-_-_-__-•.�-:.............. Attic (,''' ) Garbage Grinder ( ) aOther—Type of,Building ---------.................... No. of persons-----,---------------------- Showers ( ) — Cafeteria ( ) QI Other fixtures ------ ------------------------------------ --------- -- --- p -- ._:... - ---------------- W Design,•Flow..........._ --..07....... Mons per person per day. Total daily flow...............:. :__ ._._gallons. 9 Septic Tank Liquid capacityllons Length................ Width-.-... Diameter--- ---• ------ Depth-- ---------- xDisposatT..rench No .................. Width--------------------- Total Length......... Total leaching area..-._._. ..........sq. ft. Seepage"Pit No :............... Diameter.................... Depth below.inlet ..._ .......-_ T.otal'leaching area ...sq. ft. z Other'Distribution box ( ) Dosing tank aPercolation Test Results Performed by-----------------...:....................................................... Date......................................... Test Pit..No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water---::-..--_-..-.--._---- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------------------- - -------- ---------- ' -- - O Description of Soil----------------- - -- `" =------------------- -- ------ -- W ---------------------------------------------------------------=---------------------------------=-----••---• ----------------------=------------------------------------=------.--- = = - VNature 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been-is ed by the board f health. ,,! Signed - .............................. ` to Application Approved By.......... . .... ....... --- I/A 3----•- Date Application Disapproved for the following reasons:.......... ........................ ___-_ . t -----•-------------------------------------------------------------------•-------------•-----•••-•-------.......-----------•----------••-•-•---•----------•-------....--•-•-...---=-----------------••-- Date PermitNo......................................................... Issued......................................... =, ........ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.............................,............................................................ Tntifirttte 111 M'*11itturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by =--------------------•----•----------------------------------------------- Installer at------------------------------------------- ------------------•---------------=--------------------------------------•-------------------------------------------•-------•-------•-•---•------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- 'dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A•GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------------------------------------------- Inspector.................................................................................... 4 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.........:...................------------.....--------------------.................. No......................... FEE....................... BiriVagai lVarkii Olumitrurti.on Vrrmit Permission is hereby granted--------------- •-------•-•--•------•------•-•------------•------------•-•-•-............................................................... to. Construct (• ) or Repair ( ) an Individual Sewage`Disposal System atNo..........................................................................................................._------------ '------------------------------------------------------------------ t Street as shown on the application for Disposal Works Construction Permit No--------------------- Dated--._-------------__---__--___-____-----••- --------•--------•--••---•--••--•-----•-•----•--------•----------•---•-------•-•----....----•••--------- Board of Health DATE.........................................................•_...........-•----_... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS .' ,f TOWN OF BARNSTABLE LOCATION 2 470 �� L'Z�w ;;,7' SEWAGE# VILLAGE 6,U— 13diPN ASSESSOR'S MAP&LOT U s /D ER'S NAME&PHONE NO. 4 e 43 1 /f V SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (size) NO.OF BEDROOMS BUILDER OR OWNER .UAN / PERMIT DATE: 129�CE DATE: ��- 6 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 7 rGIN n TOWN OF BARNSTABLE LOCATION �`' ©� �� SEWAGE # VIlrLAGE /A/ —�/�/P/L ASSESSOR'S MAP & LOT //N�3� P£c7T1:s f,( IPFS�� NAME& PHONE NO. SEPTIC TANK CAPACITY tiQ� LEACHING FACILITY: (type) (size) NO. OF BEDROOMS ~B DE§iQfOWNiR OBI PE'l �T DATE: COMPLIANCE DATE: 00 Separation Distance Between the: •Maximurn 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 T J _.. w _ _ -��__-__ _ _ ���: ,., ;. 7i f t l�{ . �,g, ��o`, .. 4 >, ��x �� ��, y� f �� �:,, r ` TOWN OF BARNSTABLE LOCAj'1ON g�� Gy ew SEWAGE # VILLAGE ASSESSOR'S MAP & LOT V" 03'r7 bER46rNAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS —5 -Q OWNER LL&z a PERMITDATE: COMPLIANCE DATE:3l o G 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 1.`frxP ti 1 —T,# k o F! h� 0 31r.N