HomeMy WebLinkAbout0330 WILLOW STREET - Health 330 WILLOW STREET,
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a
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TOWN;OF BARNSTABLE
LOCATIONS,30 G—)\J kQ0 C3 3t SEWAGE# d6klo?(16
VILLAGE C ASSESSOR'S MAP&PARCEL /J 6..)X-
INSTALLER'S NAME&PHONE NO. � �� (�'d ��c✓�"t ,a(f 000
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) �C�^ (size) (600 NO.OF OF BEDROOMS V l�ox
O"ER ^ 00�).
PERMIT DATE: A COMPLIANCE DATE: 11 '
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 A
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 S C'
M Iwcd'-C 1. - c. CIO
(NIT a
aya� .� .
Aa- �
A-3
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2ppYicatiou for Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair�Upgrade( ) Abandon( ) ❑Complete System [Kndividual Components
Location Address or Lot No. \`6 W 5a %2)3 A 3 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel \ t, r^
Irstaller' N e�Addless an T- Nfd Designer's Name Address and Tel.No.
-� (Jk �My 211'4
Type of Building:
Dwelling No.of Bedrooms /v Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) (`' (`
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date Era lu�
Application Approved by �ti Date
Application Disapproved by Date
for the following reasons
Permit No. 1 �/� Date Issued
-- _--------------
- -
..xr;,�::�.,r„P,,..- .,s., .,.,,�v"tl ,M. . „�.,�,r ,:r'W4' .f17"` aRe*:� u" ^e v^,,::•`r..^�.:..-'�;✓.1.ow,•..` w _ x�' .r�- ...�-."..,,+,.n,r..�,._ti..+-i'm+,.-x-R_
{
t ,,
No. �" ` j�.r Fee
THE't;OMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Disposal 6pstent Construction 3offmit
Application for a Permit to Construct( ) Repair lv1 Upgrade( ) Abandon( ) ❑Complete System []+Individual Components
Location Address or Lot No.3 3 Gj 1`tOVV �� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel ` , h `�d'�• 'ti''d �''vf^ n
Installer's Name,Address,and Te.No Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms /VIA Lot Size sq.ft. Garbage Grinder( ) <
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures I
Design Flow(min.required) gpd Design flow/provided. gpd
Plan Date Number of sheets 'Revision Date
Title ;
f
Size of Septic Tank Type of.S'A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by l` Date
Application Disapproved by �, Date
for the following reasons
Permit No. C�1 f �/f Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V� Upgraded( )
Abandoned( )by
at �j i t� �� �,� l;Zwe� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Noa{ dated
A
Installer 7c M cr.....�yc Designer
#bedrooms /A Approved design>flow, /N—\ gpd
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date '�;" I R Inspector ��
F:..'
No .� _ (,C/ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal :6pstpm Construction Permit
Permission is hereby granted to Construct( ) Repair(v/ Upgrade( ) Abandon( )
System located at 'IX
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed,within three years of the date of this permit.
--Pi t C
Date / , /) Approved by
1 f
Commonwealth of Massachusetts �3� bozs
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments X
330 Willow Street( right side system ) "
v
Property Address . y
Edward Thornton
Owner Owner's Name '
information is �>
required for every West Barnstable Ma. 02668 7/31/2018 :4 '
page. City/Town State Zip Code Date of Inspection
-i76
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S.M.Jones Title V Septic Inspection
Company Name
74 Beldan Lane
Company Address
/ems Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com S14522
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 16.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/31/2018
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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
c� Commonwealth of Massachusetts
7� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 330 willow St West Barnstale is served by two Title V septic systems. This
report describes the right side system consisting of a 1000 gallon septic tank, distribution box and
Infiltrators. The system was found to be in proper working condition at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 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
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructedpipe(s). Th Y q P p 9 Y e
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
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 labcratory, 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 '/z day flow
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
f: Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
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 gpd
t5ins.doc•rev.6/16 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
330 Willow Street ( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
Date
CommerciallIndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
fl information is West Barnstable Ma. 02668 7/31/2018
required for every i
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 4.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leaks , vented through roof
Septic Tank(locate on site plan):
Depth below grade: 4
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:.
1000 gallons
Sludge depth:
6"
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is West Barnstable Ma. 02668 7/31/2018
required for 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
5.
Title 5 Official Inspection Form
5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�., 330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is requires for every West Barnstable Ma. 02668 7/31/2018
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
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was in good condition, no rot, water level was even with outlet invert.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working orders stem is a conditional p p g y pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
4 Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching facility was video inspected through vent and was found dry with no signs of past hydraulic
overloading.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owners Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) ,
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page, Cityrrown 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
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t5ins.doc-mv.6/16 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
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is West Barnstable Ma. 02668 7/31/2018
required for every i
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A test hole to 10' at a lower elevation on property was done at time of inspection. This excavation
resulted in no observed groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( right side system )
Property Address
Edward Thornton
Owner Owner's Name
information is requirec for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
ENVIROTECH LABORATORIES,INC.
MA CERT. NO.:M-MA 063
8 Jrm Sebastian Drive Unit 12
Sandwich,MA 0256-3
(508)888-6460 1-800-.339-6460
FAX(508)888-6446
Client Name: Thornton, Edivard Location: 330 Willow St
Address: PO Box 3381 W.Barnstable,MA
Waquoit,MA
02536 Lab Number: DW-182650
Collected By: Envirotech/MKS Date Received: 08/10/18
Sample Type: Existing Well/Title V Well Specs
r fi��� yst �>�!s =:r���i'r. �_� �-�.�,-..r fieu �7 •t e ^�;?g�a� ��k �'Y��,aw �'�'i. +� `-�^ 9, pt .„T�,q�>,i��r:. G n e `
�.•' s x �� �'ft,:� �" � ��r� ��" � t�w-�+t y ��� r[l�enls.�, a #:i
a.�yF.4 w�'7.S.rJk1,., e•S_Fo '+k59'7A��hlL�i ,.atrt 4>kG:.x L..,w.b..-r. .Y a ;n';T L_..
Analysis Requested Vidis Recantntended Limits Analysis Restsl(F Method Date Analyzed Analyzed All
Total Coliform CFU/100ml- 0 0 SM9222B 08/1012018 IRS
PH pH units 6,5-8.5 6.83 SM 4500-H-B 08/10/2018 RL
Specific Conductancen umhos/cm 500 173 EPA 120.1 08/10/2018 RL
Nitrite-N m /L 1.00 <0.006 EPA 300.0 08/10/2018 RL
Nltrate-N mg/L 10.0 1.00 EPA 300.0 08/10/2018 RL
Sodium mg/L 20.0 12 EPA 200.7 0&171.2018 NEC
Total Iron mg 0.3 <0.01 EPA 200.7 08/17/2018 NEC
.._.:..._....--Manganese ...... mglL . ..__..._. ... 0.05......_...:., ,..
0,011 EPA 200.7 08/17/2018 NEC
Volatile Organic Compounds" ug/L Se 11 e comment. 0.53' EPA 524.2 08/15/2018 NEC'
_.- ------ . ..._..
Ammonia-N mg/L 1.0 <0.50 EPA 350.2 08/14/2018 KB
Comments:
'Trace to tow levels of chloroform are occasionally detected in ground water in coastline areas.
Water meets EPA standards and is suitable for drinking for parameters tested.
Date 8/20/2018
Ronald A Saar1 v
Laboratory Dir a
I
BRL=Belmv Reportable Limits "See Attached Page 1 of 1
aCertifiealion is not available for this analyle for potable water samples.. a
New England ChromaChem
6 Nichols Street
Salem,MA 01970
978-744-6600
Massachusetts DEP Lab.M-MA072
Sample Information
EPA Method 524.2 Rev 4.1 Volatile Orglanic Compounds in Water
Lab ID: 808352
Client: Envirotech Laboratory,Inc.
Client ID: DW-182650
State: Liquid
Date Sampled: 08/10/18
Date Received: 08115/18
Date Anai zed: 08/15/18
Regulated VOC's Results u /L (uglL) Unregulated VOC's Results u 1L
Benzene ND 5 Acetone ND
Carbon Tetrachloride NO 5 Bromobenzene ND
1,1-Dichloroethene ND 7 Bromochloromethane NO
12-Dichloroethane ND 5 Bromodichloromethane NO
12-Dichlorobenzene NO 600 Bromoform NO
14-01chlorobenzene ND 5 Bromomelhane ND
Trtchloroethene ND 5 2-Butanone NO
1 1 1-Trichlorcethane ND 200 N-But (benzene ND
Vinyl Chloride ND 2 Sec-But (benzene ND
Chlorobenzene ND 100 Tert-But ibenzene NO
cis-12-dichloroethene NO 70 Chtoroethane NO
trans-1,2-dichloroethene ND 100 Chloroform 0.53
1 2-Dichloro ro ane ND 5 Chioromethane ND
Eth (benzene NO 700 2-Chlorotoluene ND
Styrene NO 100 4-Chlorotoluene NO
Tetrachloroethene ND 5 Dibromochloromethane NO
Toluene ND 1000 1 2-Dibromo-3-Chloro ro ane ND
X lenes Totai ND 10000 1 2-Dibromoethane ND
Methylene Chloride ND 5 Dibromomethane ND
1 2 4-Trichlorobenzene NO 70 1 3-Dichlorobenzene ND
112-Trichloroethane NO 5 Dichlorodifluoromethane ND
11-Dichloroethene ND
1 3-Dichloro ro ane ND
2 2-Dichloro ro ane IND
1 1-Dichloro ro ene IND
Hexachlorobutadiene ND
Iso ro (benzene ND
P-1sopropyltoluene ND
Methyl-tert-butyl ether NO
Naphthalene ND
N-Propylbenzene ND
1112-Tetrachloroethane NO
1 1 2 2-Tetrachloroethane ND
1 2 3-Trichlorobenzene NO
Trichlorofluoromethane ND
1 2 3-Trichloro ro ane ND
1 2,4-Trimeth (benzene ND
1 3,5-Trimeth (benzene IND
3
Method Detection Limit=0.5 u /L
Recoveries of internal Standards %
Benzene-d6 _ 100
4-Bromofluorobenzene 191 MCL TTHM's=80 ug/L
1 2-Dichlorobenzene-d4 linn Method Detection Limit=0.5 ug/L
Analysis performed per 31 OCMR42
f
Electronically signed and approved by Mr.Bruce A.Bornstein,Lab Director Date: 8/16/2018 u
Commonwealth of Massachusetts /` / 1-2,F
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( rear system ) N
Property Address ,
Edward Thornton ='
Owner Owner's Name / U a
information is West Barnstable t! Ma. 02668 7/31/2018
required for every
page. City/Town State Zip Code Date of Inspection C:
1:3t
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S.M.Jones Title V Septic Inspection
Company Name
74 Beldan Lane
Company Address
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com S14522
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
7/31/2018
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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification. (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 330 willow St West Barnstale is served by two Title V septic systems. This
report describes the rear system consisting of a 1000 gallon septic tank, distribution box and a 1000
gallon precast leach pit. The system was found to be in proper working condition at the time of
inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
CIA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is West Barnstable Ma. 02668 7/31/2018
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less'than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must.indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<lo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l�
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information.For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6116 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
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owners Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leaks , vented through roof
Septic Tank(locate on site plan):
Depth below grade: .5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gallons
Sludge depth:
6"
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
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
3'
Scum thlickness
3° I
�I
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was replaced for inspection. Permit# 2018-246
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1x1000
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
s.a.s. consists of a precast 1000 gallon leach pit. Pit was found dry at time of inspection with a stain
line 2'from bottom.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
1101
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( rear system )
Property.Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. CitylTown 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
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t5ins.doc•rev.6/16 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is required for every West Barnstable Ma. 02668 7/31/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12+feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A test hole to 10' on property was done at time of inspection. This excavation resulted in no observed
groundwater. Bottom of pit is 8.5' below grade.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 Willow Street( rear system )
Property Address
Edward Thornton
Owner Owner's Name
information is West Barnstable Ma. 02668 7/31/2018
required for 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
ENVIRO TECH LAB ORA TORIES,INC.
MA CERT.NO.:M-MA 063
8 Jan Sebastian Drive Unit 12
Sandwich,NIA 02563
(508)888-6460 1-800-339-6460
FAX(508)888-6446
Client Name: Thornton, F*ard Location: 330 willow St
Address: PO Box 3381 W.Barnstable,MA
Waquolt,MA
02536 Lab Number: DW-182650
Collected By: Envirotech/MKS Date Received: 08/10/18
Sample Type: Existing Welirritle V Well Specs
ter i._Y:'°" _ s'h
}fdE Y ri ; s r s & _= Pe (Jltt7nenlp' y
o�rrlir gift a :¢ 1picofleeted TimeCateled ., ;
�:n �.a�-ems ` s- �sA` � '"rt `z�. .��
Analysis Requester/ Units Recommended L1ndis Ana4jwk Rcvulf Melhod Date Analyzed Analyzed By
Total Coliform CFU/100ml- 0 0 SM9222B 08/10/2018 RS
............ ._..._.. .
pH pH units 6.5-8.5 6.83 SM 4500-H-B 08/10/2018 RL
Specific Conductancen umhos/cm 500 173 EPA 120.1 08/10/2018 RL
-— ....._
Nitrite-N mg/L 1.00 <0,006 EPA 300.0 08/10/2018 RL
Nitrate-N mg/L 10.0 1.00 EPA 300.0 08/10/2018 RL
Sodium mg/L 20.0 12 EPA 200.7 08/17/2018 NEC
Total Iron mg/L 0.3 <0.01 EPA 200.7 08/17/2018 NEC
..._.._._....,-•Manganese-...a... mg/L .._. _..... 0.05`......__....,r .
0.011 EPA 200.7 08/17/2018 NEC
Volatile Organic Compounds* ug/L See comment. 0.53` EPA 524.2 08/15/2018 NEC*
_. _ -..- �__.... _. .,.._.._.
Ammonia-N mg/L 1.0 <0.50 EPA 350.2 08/14/2018 li
Comments.
*Trace to low levels of chloroform are occasionally detected in ground water in coastline areas.
Water meets EPA standards and is suitable for drinking for parameters tested.
Date 8/20/2018
i
Ronald J.Saari
Laboratory Dir ct
f
r
BRL=Below Reportable Limits 'See Attached Page 1 of 1
aCerlhcatlon is not available for this analyle for potable water samples..
New England ChromaChem
6 Nichols Street
Salem,MA 01970
978.744.6600
Massachusetts DEP Lab.M-MA072
Sample Information
EPA Method 524.2 Rev 4.1 Volatile Organic Compounds in Water
LablD., 808352
Client: Envirotech Laboratory,Inc.
Client ID: DW-182650
State: Liquid
Date Sampled: 08/10/18
Date Received: 08/15/18
Date Anal ed: 08/15/18
Regulated VOC's Results ug/L (ug/L) Unregulated VOC's Results uc/L
Benzene NO 5 Acetone NO
Carbon Tetrachloride NO 5 Bromobenzene NO
11-Dichloroethene NO 7 Bromochloromethane. NO
12-Dichloroethane NO 5 Bromodichioromethane NO
12-Dichlorobenzene NO 600 Bromoform NO
14-Dichlorobenzene ND 5 Bromomethane NO
Trichloroethene NO 5 2-Bulanone NO
1 1 1-Tdchioroethane NO 200 N-Bul ibenzene NO
Vinyl Chloride ND 2 Sec-But (benzene NO
Chiorobenzene NO 100 Tert-Bui (benzene NO
cis-12-dichloroethene NO 70 Chloroethane NO
trans-1,2-dichloroethene NO 100 Chloroform 0.53
1 2-Dichloro ro ane NO 5 Chloromelhane NO
Ethylbenzene NO 700 2»Chlorotoluene NO
Styrene NO 100 4-Chlorotoluene NO
Tetrachloroethene NO 5 Dibromochloromethane NO
Toluene NO 1000 1 2-Dibromo-3-Chloro ro ane NO i
X lene Total NO 110000 1 2-Dibromoethane NO j
Methylene Chloride NO 5 Dibromomethane NO
1 2 4-Trichlorobenzene NO 70 1 3-Dichlorobenzene NO
112-Trichloroethane NO 5 Dichlorodifluoromelhane NO !
11-Dichloroethane NO
1 3-Dichloro ro ane NO
2 2-Dichloro ro ane NO
1 1-Dichloro ro ene NO
Hexachlorobutadiene NO
Iso ro (benzene NO
P-Isopropyltoluene NO
Methyl-tert-butyl ether NO
Naphthalene NO
N-Propylbenzene NO
1112-Telrachloroethane NO
1 1 2 2-Tetrachloroethane NO
1 2 3-Tdchlorobenzene NO
Trichlorofluoromethane NO
1 2,3-Trichloro ro ane NO
1 2 4-Trimeth (benzene NO
1 3 5-Trimeth (benzene ND
Method Detection Limit=0.5 ug/L
Recoveries of Internal Standards %o
Benzene-d6 1100
4-Bromofluorobenzene 191 MCL TTHM's=80 ug/L
1 2-Dichlorobenzene-d4 1103 Method Detection Limit=0.5 ug/L
Analysis performed per 31 OCMR42
Electronically signed and approved by Mr.Bruce A.Bornstein,Lab Director Date: 8/1612018
a
Town of Barnstable
� Op THE Tp�
Regulatory Services
anxxsrnsi a Thomas F. Geiler,Director
MAM
ArFD .p Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
'. 330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is required for W BARNSTABLE MA 02668 8/21/07
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in="any
way.
Important:filling A. General Information = v,
When ng out ,�.
forms on the i
computer,use
1. Inspector:
only the tab key
to move your DOUGLAS A. BROWN y�Z3
cursor-do not Name of Inspector c:
use the return M 1
key. D.A. BROWN
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
CitylTown State Zip Code
508-420-4534 S 14297
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
8/21/07
Inspe ' Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the'system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""'This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Title V Inspection Form.doc•MOB
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M y 330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
requiratifor W BARNSTABLE MA 02668 8/21/07
required for
every page. Cityrrown 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:
® 1 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:
2 SYSTEMS ON PROPERTY BOTH PASS
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the❑for the following statements. If"not
determined;" please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
Title V Inspection Form.doc•08/06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
f
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
` 330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is W gARNSTABLE required for MA 02668 8/21/07
every page. Cdyrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Title V Inspection Forrn.doc•0&06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
informaton is W BARNSTABLE
required for MA 02668 8/21/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %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.
Title V Inspection Form.doc•0&06 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is W BARNSTABLE required for MA 02668 8/21/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ 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.
Title V Inspection Form.doc•0&06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a't 330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is W gARNSTABLE required for MA 02668 8/21/07
every page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
Title V Inspection Form.doc-08106
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
I II
Commonwealth of Massachusetts
DIM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
y� 330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is W gARNSTABLE required for MA 02668 8/21/07
every page. Cityr town State Zip Code Date of Inspection
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
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)):
Sump pump?
❑ Yes ® No
Last date of occupancy: CURRENT
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
S
Last date of occupancy/use:
Date
Other(describe):
i.
Title V Inspection Form.doc-08106 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.•''t 330 WILLOW ST
Property Address
SCHULTZ
Owner Owners Name
information is W BARNSTABLE required for MA 02668 8/21/07
every page. Cdylrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was cuantity 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 a copy of the DEP approval.'
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
SYSTEM ONE1997 SYSTEM TWO 1989
Were sewage odors detected when arriving at the site? ❑ Yes ® No
e
Title V Inspection Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
<�( 330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information
equir at for
is W BARNSTABLE required for MA 02668 8/21/07
every page. Clty/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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:
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene y [I 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: 2 ONE THOUSAND GALLON
TANKS
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Title V Inspection Fonn.doc-08I06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is required for
W BARNSTABLE MA 02668 8/21/07
.
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
ONLY ONE OCCUPANT BOTH TANKS LOOK VERY CLEAN NO HEAVY SOLIDS
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Tide V Inspection Forrn.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is W BARNSTABLE required for MA 02668 8/21/07
every page. Cltyfrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Title V inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r` 330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is W BARNSTABLE required for MA 02668 8/21/07
every page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why: -
SYSTEM ONE HAS NO OBSERVATION PORTS SYSTEM TWO WAS OPENED
Type:
® leaching pits number: 1
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SYS TWO PIT OPENED THERE IS ABOUT 3 FT OF USABLE SPACE SYS ONE NOT OPENED
DUE TO NO OBSERVATION PORT
Title V Inspection Form.doc•08106
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments
330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is W BARNSTABLE required for MA 02668 8/21/07
every page. &Wfown 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.):
Title V'rnspecfon Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
r 330 WILLOW ST
Property Address
SCHULTZ
Owner Owner's Name
information is required for W BARNSTABLE MA 02668 8/21/07
every page. Cityffown 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.
y
3C&C
Gti, sa,�tf wekr
7
Nr�
�1�r1 �� SyStiC!V\ Z.
tot �
Title V fnspecton Form.doc•0806 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
330 WILLOW ST
Property Address
SCHULTZ
Owner Owners Name
information is W BARNSTABLE required for MA 02668 8/21/07
every page. Cdy/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: SYS-1-6FT/SYS TWO-1'9"
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:
SEE ATTACHED COPY FROM PREVIOUS INSPECTION REPORT
a
Tide V Inspection Fomt.doc•08/O6
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
property
Address: 3
Owner:
Date of Inspection:
Depth to Groundwater / / Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
I
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
//Use USGS Data
ih Groundwater Elevation. ust be completed)
Describe in your own words how you established the Hig M
/4/'/' Gal
y �%.5.�,/G. /.a I�/af�p �.T<-�-��:L ! % G�-�,; 4,a T!'��i.�✓� ✓� /-�TL
�Qac-fi41
PiT % 5 is 1 ;aeh=/�. �l�� �� GoI2/>�'�>��✓ �'�G.�✓r, iS 7 "G,'.
j I/e
SysM i s L-f t IS���✓
Page 10 of 10
(revised 04/25/97) '
TOWN OF BARNSTABLE
LOCATION ► C�'-�ka� �� SEWAGE # -
s. _
VILLAGE W �v �� ASSESSOR'S MAP & LOT /?�!- n a
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY }��
LEACHING FACILITY: (type)!T C�+(�/. �l(size) ✓� Yc�
NO.OF BEDROOMS `
BUILDER OR OWNER 4:n.C
PERMIT DATE: :7 -am -7 COMPLIANCE DATE:
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
S
49
j9
8-3_.1.-
2
(mow $w, tt�T✓� f�O 4—
4/ �3
/3-/-
No. 7 6 ►� w F �� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Z____
Yes
A
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MA HU SS C S ETTS
01ppYication for Oie;ponf *pgtem Conotruction Permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. O (A,)Z\\ot.v bT, , Owner's Name,Address and Tel.No.
er'
Assessor's Map/Parcel p��1ST�b' r 'r4 D V'F
Inst�allerr's Name,Address,andl-Tel.No. Designer's Name,Address and Tel.No.
` Q
Type of Building:
Dwelling No.of Bedrooms IS Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow a gallons per day. Calculated daily flow ({Ct gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 5—X k (OOc.) � Type of S.A.S.
Description of Soil (✓o F-I- b± l�
Nature of Repairs or Alterations(Answer when applicable)
tv t LTJ'a U h/ S 09e.
Q rtn.7T 0=0-,
14
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Bo
Si ed Date 7-c_4 t l
Application Approved by IeP Date
Application Disapproved for the following reasons
•
Permit No. !27 — 3a 7 Date Issued 7
———————————————————————————————————————
13
Fee
x
THE COMMONWEALTH OF MASSACHUSETTS Entered in computers
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for ;Digpoga[ *pgtem Congtruction Permit
Application for a,Permit to Construct( )Repair( v)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3 3 Q (J\1 OtL) �'�'� Owner's,Name,Address and Tel.No.
Assessor's Map/Pazcel �g�►6�h�s�c b1 e. PA 1 ��
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type ofiBuilding:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 gallons per day. Calculated daily flow 3(4 Ct gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Zt<k 9 n&_ l CCc' Type of S.A.S. 1 �n Ck�GIT�
V
Description of Soil In'\� S �� tam t)'e PZ
Nature of Repairs or Alterations(Answer when appl'cable)
Date last inspected:
Agreement: ,° r u
The undersigned agrees to ensure the construction and maintetce of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Codeand not to place the system in operation until a Certifi-
cate of Compliance has been issued 'y~Bo
Signed Date 7-C) l
Application Approved by G±T I Date
Application Disapproved for the following reasons
i
Permit No. 7 r 341 7 Date Issued --2-2 —l"7
— ---=—=4-------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance-
THIS IS TO CERTT haee On.-si�,,t2,a,,a Disposal System Constructed( )Repaired ( )Upgraded
Abandoned( )by
at 1 73 3D hJ oUc 5\VC-c l 'AV_14Ss has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 �7 dated
Installer ', Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date - 6.i at '� Inspector
r
———————————————————————————————————————
j
No. / 2` _Xt! Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigoml *pgte✓ongtruction Permit
Permission'is hereby granted to Construct( )Repair( )U rade( )Abandon( )
System located at 320 LU \cw ST
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: -7 —_).2 Approved by C 44141I-+.4 / le
d
i
NOTICE: This:Form is;to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated `7-at -cl 7 , concerning the
property located-at 3V I meets all of the
following criteria: -
• There are no wetlands within 300 feet of the proposed;septic system-
• There are no private wells with^in_150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE: G
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER"
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
w
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CERTTFTED SEPTIC SYSTEM REPORT
[7RECOW.D.
JUN101997
LOCATION
330 WILLOW ST . TOWN OF CA
W . BARNSTABLE , MA
MAP 131 PARCEL 025 ;
PREPARED FOR
SELLER
MR. & MRS . CEM ANDAC
330 WILLOW ST .
W . BARNSTABLE , MA 02668
BUYER
MS . MARGARET SCHULTZ
P .O. BOX 385
COMMAQUID, MA 02637
PREPARED BY
HILLIARD HILLER
P .O. BOX 250
CENTERVILLE , MA 02632 �
508-778-1472
3
bl"�
3
TOWN OF BARNSTABLE
LOCATION 332 Cd/lL sr SEWAGE #
VILLAGE 4', Xi eAI . ASSESSOR'S MAP & LOT /3t ao�s
NAME&PHONE NO. 111,WZW 52>9-7,I&—
SEPTIC TANK CAPACITY /4-122
LEACHING FACILITY: (type) (size) G
NO.OF.BEDROOMS
8H$BEK0R OWNER -*,�ki
S1-ye/
PERMIT DATE:::!�Z/Vz! COMPLIANCE DATE:
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 leac 'ng facili ) Feet
Furnished by
3Tofi,�C 4+9L L � .
4
�Rovr Qa�Z
s
S>:5%.7 " • s, SS, vow
IlkA . -
j:
J`Yb%t',e, d oZ CGS%
f
\ COMMONWEALTH OF MASSACkSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
C� DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. IVIA 02108 61 i-292-5i00
i FRE
WLL1A�1 F.WELD TRUDY COXE
Gc•vemo: 97SecretaryAF:GEO PAUL CELLUCCI AVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOCommissioner
PART A
CERTIFICATION
Property Address: Address of Owner:
Date of Inspection: ����� (If different)
Narne of Inspector: A/ /'!/G4;_161*z
am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:
Mailing Address: 4;,�K oZbV <= l ,;
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
amasses
— Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: / ✓�% Date: 7�
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Checlr/:V B, C, or D:
A] SYSTEM PASSES:
LZI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certifitate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(rovimad 04/25/97) i Paya 1 of 10
DEP on the World Wide Web http.lnvww magnet state ma.ualdep
Printed on RecyCled Paper
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
7 2-
Property Address: cv//GGUG✓ s 7
Owner:
Date of Inspection:
BJ SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high s tic water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or Tneven distribution box. The system will pass inspection if(with approval of the
Board of Health), Describe observati nsi
broken pipe(s) ar replaced
obstruction is re oved
distribution box s levelled or replaced
The system required pumping mo than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced'
obstruction is emoved
C) FURTHER EVALUATION IS REQUIRED BY T E BOARD OF HEALTH:
Conditions exist which require further a aluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environm t.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLI HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 0 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 ARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING 14 A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has /ae
ank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a suer supply.
The system has tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has ank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water sul, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free flution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. d used to determine distance (approximation not valid).
3) OTHER
(zeviaad 04/25/97) Papa 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
�-
Property Address: O���
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. Th Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or ystem component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluen to the surface of the ground or surface waters due to an.overloaded or clogged SAS or
cesspool. t_
Static liquid level in the distrib tion box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is le s than 6" below invert or available volume is less than 112 day flow.
Required pumping more tha 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation
Any portion of a cesspo/, cc
r privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspor privy is within a Zone I of a public well.
Any portion of a cesspor privy is within 50 feet of a private water supply well.
Any portion of a cessp?I or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water qualify analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volaltile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply o large systems in addition to the criteria above:
The system serves a facilityiwith a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety an the environment because one or more of the following conditions exist:
Yes No
the system is ithin 400 feet of a surface drinking water supply
the system is ithin 200 feet of a tributary to a surface drinking water supply
the system i located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a
public wat supply well)
The owner or operator of an such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5. 0 and 6.00. Please consult the local regional office of the Department for further information.
{rovia.d 04/25/97) Paga 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection: G/s�y7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
`!es No
✓ _ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the;system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
w _ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility, or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
r _ The site was inspected for signs of breakout.
_ All system components. excluding the Soil Absorption System, have been located on the site.
ci•. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(rovi�od 04/25/97) pago 4 of 10
II .
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection: 4
/5 Aq 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: S
Garbage grinder (yes or no):—*�
Laundry connected to system (yes or no)- YfS
Seasonal use ryes or no):Lvv
Water meter readings, if available (last two (2i year usage (gpd): L�igLc
Sump Pump (yes or no): N l
Las° date of occupancy: i L l'
COMMERCIIreaings,
STRIAL:
Type of esta :
Design flow: allons/day
Grease trap yes or no)_
Industrial Wing Tank present: (yes or no)_
Nor.-sanitaryscharged to the Title 5 system: (yes or no)_
Water meter if available
Last date of occ pane:
i
OTHER: (Desc ibe) _
Last date of o upancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information
System pumped as pan of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
;peptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: /g JS�
Sewage odors detected when arriving at the site: (yes or no)
(rovined 04/25/97) Page 5 of 20
r -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: G14,
Owner:
Date of Inspection: /s/y7
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: cast iron _40 PVC_other (explain)
Distance from private wat r supply well or suction lint
Diameter
Comments: (condition of)oints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade: /
Material of constru ion: Leoncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, li t age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: X ���` r%�j lae4o
Sludge depth: 1
Distance from top of sludge to bottom of outlet tee or baffle: /j-
Scum thickness: IF c
Distance from top of scum to top of outlet tee,or baffle: 7 B
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Ti9X/` Zak= i?G.�}I, A'o
GREASE TRAP:
(locate on site T
Depth below gMaterial of conon: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thicknes .
Distance from op of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
!Date of last p mping:
Comments:
;recommen tion for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
Integrity, ev dence of leakage, etc.)
;revise 04/2S/971 Pago 6 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
6Y5%CM 2 SYSTEM INFORMATION (continued)
Property Address: 3 5,:2 �//G��'� 5i' / 4/ lslaIe4/
Owner: Atl"q /9 C
Date of Inspection: 615,15�7
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _con ete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gall ns
Design flow: g lons/da%
Alarm level: arm in working order _ Yes; _ No
Date of previous pump/ndition
Comments:
(condition of inlet tee, of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on,site plan)
Depth of liquid level above outlet invert: —�^
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) d l'PX La?
/�o1/G/� /�i? po.�s •yoT �i��'•��' /� � Pam'/-fit��-G, 7h'� .fro is
/=r/GG- off= SoG/%�S s� �T sf�`oyc� .eS<' /dl�i�►ic',�'!�7 od/T,
PUMP CHAMB R:_
(locate on site Ian)
Pumps in wo ing order: (Yes or No)
Alarms in wo ing order (Yes or No)
Comments:
(note conditi n of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 SO
Owner:
Date of inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet in ert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool m st be pumped as part of inspection)
Comments:
(note condition of soil, sign 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, sig s of hydraulic failure, level of ponding, condition of vegetation, etc.)
M
(revised 01/25/97) Page 8 of 10
P
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SysTr1/L! � a
SYSTEM INFORMATION (continued)
Property Addres : 3 3,1 cd/G c:
Owner: /T7ir7 '?x-.O1 C �
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes intohouse)
e•
/ V
� r
L )
q
O
I _ �
4C
(revised 04/25/97) pay 9 of 10
o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 30
Owner:
Date of Inspection:
Depth to Groundwater !%I�Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
✓Determine it from local conditions
Check with loca! Board of health
Check FEMA maps _
Check pumping records
Check local excavators, installers
//Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
j� G�..S,�✓G /.-� h`/.a/�O LTr-��L:G 1% G��/_fS C�,�T�'!�nj.�✓� � r� i1�l��,
C'/ ..e' ! 7
�fi/,'.1/Si�Git Gls 5i�z�f i<�,z �iTiL i3,T .�Gi'.��Ti✓i✓ �
j llL' eG',,✓5s?Tc��i?r
2,,
(rovisod 04/25/97) Pago 10 of 10
l TOWN OF BARNSTABLE
LOCATION �, W i�w� �� SEWAGE# G
VILLAGE, ASSESSOR'S MAP_& LOT I AL
INSTALLER'S NAME&PHONE NO. Q
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)C�+('/. ���(size)
NO.OF BEDROOMS
BUILDER OR OWNER i,
PERMIT:DATE: ��r�l�9.7 COMPLIANCE DATE: '�/—
' 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,W- etland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
S ion ,
)9 1
q3 1z9'
8-3
ti
2
i
J -� �
CERTIFIED SEPTIC SYSTEM REPORT
F1E
0 1997
LOCATION
HEALTH C:-^T
330 WILLOW ST . TOWN OF CAl:, -." --E
W . BARNSTABLE , MA
MAP 131 PARCEL 025
PREPARED FOR-
SELLER � � 36-7
MR. & MRS . CEM ANDAC 2L?-7
330 WILLOW ST . d 7 Z
W . BARNSTABLE , MA 02668 / 0 ( t�
BUYER
MS . MARGARET SCHULTZ
P .O . BOX 385
COMMAQUID, MA 02637
I
PREPARED BY
HILLIARD HILLER
P .O . BOX 250
CENTERVILLE, MA 02632
508-778-1472
COMMONVN'EALTH OF MASSACHL'SETTS
0' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. NIA 02108 61 i-292.5500
RECEIV7D�
WILLIAM F.WELD TRUDY COXE
Govcmo: Secretary
AF.GEO PAUL CELLUCCI U N O 199DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F RM HE�.I_TF.ET.,.n Commissioner
PART A TOWN Or i 1 :..
5ySrx," CERTIFICATION '
Property Address: G✓ld1,a,-4/ y Address of Owner:
Da`e of Inspection: G%7/`i7 (If different) w
Name of Inspector:
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:
Mail ingAddress: AO ,(,��r o?9 G�lt�lGc%.� /2e� Gv?6�%
Telephone Number: 608 --22P— f 7.2
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system: Q "'7
Passes 0 7 2 2- `?7
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority G
tiF"a�ls
Inspector's Signature: 240 Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, 8, C, Or I�
A] SYSTEM PASSES:
I have not found any inform ion which indicates that the system violates any of the failure criteria as defined in 310 CMR 13.303.
Any failure criteria not evalu ted are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PAS ES:
One or more system corn vents as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replace ent or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank ' metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (an ched) indicating that the tank was installed within twenty (10) years prior to the date of the inspection; or
the septic tank,' hether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is immin nt. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
.vived 04/25/97) Pape 1 of 10
DEP on the World Wide Web http:Hwww.magnet.state.ma.usidep
Printed on Re ycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33� Gd/GGci�ci ST C.✓. /vl/�,Q�
Owner: /Gj/'-1
Date of Inspection: G1,,7�j
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static ter level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or unev distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are repl ed
obstruction is removed
distribution box is lev led or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Boar of Health):
broken pipe(s) are re laced
obstruction is remov
C) FURTHER EVALUATION IS REQUIRED BY THE BO RD OF HEALTH:
Conditions exist which require further evaluati n by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF H LTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEA TH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 fee-of a surface water
Cesspool or privy is within So fee of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A NNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank a d soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank Td soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank nd soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank nd soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, u ess a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method uied to determine distance (approximation not valid).
3) OTHER
j
1
rcead D4?25/47)
(rev?c:.. Page 2 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
SYST��r / CERTIFICATION (continued)
Property. Address: j,sp
Owner:
Date of Inspection: G131;
D] SYSTEM FAILS:
You must indicate either "Yes" or"No" as.to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
_ Backup of sewage into facility or system component due.to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to ari`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.
A-" Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day floes.
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
T
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
L. Any portion of a 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 piny is within a Zone I of a public well.
V 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No as to each of the following:
The following criteria apply o large systems in addition to the criteria above:
The system serves a facility ith a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety an the environment because one or more of the following conditions exist:
Yes No
the system is wi in 400 feet of a surface drinking water supply
the system is w' hin 200 feet of a tributary to a surface drinking water supply
the system is I ted in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone ll of a
public water s pply well)
The owner or operator of any su h system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 nd 6.00. Please consult the local regional office of the Department for further information.
revised 04/25/97) Pa • 3 of 10
t 4
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Sys:x.•? ��
Property Address:
Owner:
Date of Inspection: 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_✓ _ None of the system components have been pumped for at least two weeks and the:system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
!✓ _ As built plans have been obtained and examined. Note if they are not available with N/A:
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components.eluding the Soil Absorption System, have been located on the site.
I✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
co•.�,o �vv7. 61a l /.ems/,ol' TA, -111C.
The size and location of the Soil Absorption System on the site has been determined based on:
_✓ The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
v _ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/35/97) page 4 of 10
f
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3Av � k
Owner: /yr�i1, �1rvp�fC
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: R.p.d./bedroom for S.A.S.
Number of bedrooms: 3 _
Number of current residents:A
Garbage grinder (yes or no):_/O
Laundry connected to system (yes or no):-�Z
Seasonal use (yes or no):,&±�
Water meter readings, if available (last two (2) year usage (gpd): Gyi�zL
Sump Pump (yes or no):
Last date of occupancy:
COMMERCIAUINravailable
•
TvpE of establishm
Design flow: av
Grease trap preseno)_
Industrial Waste Hk present: (yes or no)_
Non-sanitary wastd to the Title 5 system: (yes or no)_
Water meter readable
Last date of occup cy:
OTHER: (Desch
Last date of occu anov.
GENERAL INFORMATION
PUMPING RECORDS and source of information
System pumped as part of inspection: (yes or no)-A±�"
If yes, volume pumped gallons
Reason for pumping
TYPE OE SYSTEM
t/ 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)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: ��� � j/�/
.G��-/— z7 TO IIA,7 /V
Sewage odors detected when arriving at the site: (yes or no)JV—a
(revised 04/251S7) page 5 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: a !�//L�—O� "'S� w y'/9,e.�/•
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan
Depth below grade
Material of constru ion: _cast iron _40 PVC _other (explain)
Distance from priv to water supply well or suction lir•t
Diameter
Comments: (cond ion of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: t/
(locate on site plan)
y A '
Depth below grade /G 9',::'
Material of construction: Koncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: Y dr t o�'I8°
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) GvvLO !/OT TH,e
GREASE TRAP:
(locate on site pla )
Depth below gra e:
Material of const uction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from p of scum to top of outlet tee or baffle:
Distance from ttom of scum to bottom of outlet tee or baffle:
Date of last p ping:
Comments:
(recommenda ion for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evi ence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
5 y5 i r c� / SYSTEM INFORMATION (continued)
Property Address: 5% Gf/.
Owner: .ty�i-� iyvoiyC
Date of Inspection: 4�/31c7
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of constructs n: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Deign flow.jinlett
gallons/da�
Alarm level. Alarm in working order _ Yes; _ No
Date of prevg
Comments:
(condition ofndition of alarm and float switches, etc.)
DISTRIBUTION BOX: !./
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
4�°,�i✓ T��� � " /max.
PUMP CHAMB R:_
(locate on site Ian)
Pumps in wo ng order: (Yes or No)
Alarms in wo ing order (Yes or No)
Comments:
(note conditio of pump chamber, condition of pumps and appurtenances, etc.)
(r.vi..e 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Lri/G`-a4✓
Owner: A71,r+ ffciOf�C
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): t/
(locate on site plan, if possible, excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number: w
leaching trenches, number•length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
L%l.�l//Q Lr/A.S' U/? /P✓iy I�iSL'/L
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet mve :
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool m st be pumped as pan of inspection)
Comments:
(note condition of soil, st s of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construct' n: Dimensions:
Depth of solids:
Comments:
(note condition of s il, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/ 7) Pay 8 of 10
r
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addres '✓S 1✓� �z/�Gi-'ow S%/ L� ���/�
Owner: fiat ff,!/Ol�C
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
i
r
O
a
/ha
/
f
4
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t ,
(revised 04/25/91) Page 9 of ,10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: C
Date of Inspection: G/315-
Depth to Groundwater -r-Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA neaps
Check pumping records
Check local excavators, installers
use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
)
fLjoL�i'�T/��/v �'i✓? 5y��2,�r ,47-
Zfa j/fe /?�v7isi c�v �
1
i�e:vygad 0;/?S/91) Page 10 of 10
TOWN OF BARN.STABLE
IIOCATIO14 L111IO&Y 'S J SEWAGE #
VILLAG ASSESSOR'S MAP lCc LOT _
II INSTALLER'S NAME Sk PHONE NO.
SEPTIC TANK CAPACITY �L�.
LEACHING FACILITYs(CyPe) f,'t ,(size) 3
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERC._
BUILDER OR OWNER
DATE PERMIT ISSUED:___
DATE COZf PLIANC:E ISSUED:
VARIANCE GRANTED: Yes NG
a
L
TOWN OF BARNSTABLE
LOCATION 330 Ca./lL ST SEWAGE # -87- 81C i
VILLAGE ASSESSOR'S MAP& LOT IL oas
2 NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS -3
RbM-D'OR OWNER *,�4,
PERMTTDATE: !?ZI�' , l COMPLIANCE DATE:
Separation Distance Between the: Feet
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
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 leac ng facility) Feet
Furnished by
STop� tayt Z
� �Ro� pent ' ' .',C� . . .� ;
� �':4�
�id/t 4L
� ���• Q
a w�zL
�o/��is ��
� ii i �
�,.\
- � � �
b
4
,. �
i j
���
No. -- ---. ---
Fus.1...20.00..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town OF Barnstable
........ ................. ......--.............-----......._.....•-•................._.........
Appliration for Dhipwi al Wark.5 Tons rurtiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
��O Willow Street West Barnstable
.......................... .. -••-•-•-----------••--................ ...............I..................................................................................
Location.Address or Lot No.
Janes Andac _
---------------------------•----•------..--- -•---........_...........-----•......•--•------ ---..................-•-•-•................ •--........... .. ----•--••..................••-
owner Address
w J.P.Macomber & Son Inc .
•---•-•----•------•..................................................................•••--•....... .....................---.............---•-•...........-••--•--•••........._._..................•--
Installer Address
U Type of Building Size Lot.....................
ot...........................Sq. feet
Dwelling`--No. of Bedrooms................ .........................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building ............. No. of persons....................... Showers — Cafeteria
aOther fixtures .-----•-----•---••---------------------------------------••-••--•...••-•••-••••••-•-•-----------••-•..........-•--•--•••-..................---.....--
Q
W Design Flow............................................gallons per person per day. Total daily flow....................__..........,_.._.......gallons.
WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a est Pit No. I................minutes per inch Depth of Test Pit..___......_..__... Depth Date__._......water
Test Results Performed b
_ to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-•...............••-•......-•••••••--- •-•-•-••••-•.._............--•-•-••--• •--•---••---------.......----------.... ...._..................-•.•-•--
0 Description of Soil...............................................Sand._.......----•--••-••----•-------------.......•---•-•••---•---------•-•••-••........_......---•-•.........•--
V ............................................••---•-•--•-• --••-•.......••--•---•--•-•--•---•••----•--...•-••--..•----••-•••--•••-••-•--••-•-----••----•----••--•-----••-•-•-••-•----•---•-•-----------
W
UNature of Repairs or Alterations—Answer when applicable--------IXM.........................................................................
1-1000 _gallon tank � 1-1J00 -allonpit'._ .. •- •---•--•--•-•-- ••--- •-----••-••••••-••----••--------•----•....................••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI:E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued botne and of l alth.Signe Application Approved By. --•-•-•. .. A...... ........ =
` Date
Application Disapproved for the following reaso s. --•---••.......----•------•----•••••---•-••-•••••••-•--••-••-•-------....•••--•-----•....................•-•---
--•---••-•-•--.................................................... --------------------------••••......--
ID Date
Permit No... . .....f- I .................... Issued_.... _ .,------
ate
No. .............. ....... '.... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF . HEALTH
.....................OF......�?.rCl...St................lt?
....................................................
Allp iration for Mnpunal Works Tongtrnrtiun rranit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
.?-0 Wv llow Street West Barns able
....... .................. .. .... --••--•-•-•........,. . ..........----•--•...---•-----•--........•. ---•------------...--••-•..........--••-•
Location-Address or Lot No.
.................................................................................................. ..................................................................................................
W _. Owner Address
W ..... _'.;:...... O.n; �.. � ��on 7ni: ......-•--•--••--••..... ............................••------....._.................--....---
Installer Address
d Type of Building Size Lot............................Sq. feet
U
U Dwelling=No. of Bedrooms............... .......................•..Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons.............•.............. Showers ( ) — Cafeteria ( )
g ............................................ . ._. . .. . . -- -....---- •-•----•--•-•--=--- --- ------------------------------•--------------•-.�•-----•
Other fixtures --------------------- - - - -- ••----
W Design Flow gallons per person per day. Total dailyflow............................................gallons.
WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--___----___------.--.-.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ •--••••--••-------------•---•••----•••-•--•-•-•••--.-----...........----...........------------------.._...-•---•..........................................................
ODescription of Soil..................................................•---•---------•------------•---------------•--------------------•------------•--------•------------••........._..••---
x 'Sand
U -•••••-•-••••••-•-••---•••------•---•-----•----•...-------•--••---•----------------------------•......--------------•-----••-••--•--•---------------•-------•---•-•-•-•------------•-•-••-•------------
W
----------------------------------•-------------------------------------------------••--•-------•---------------------------------------------------------------------------------------............--
U Nature of Repairs or Alterations—Answer when applicable-------1 XTYX--------.................................................................
1-10r)n a lon tankL l-1{; C:� allon n? t.
..........................................=--..........---•-----•-•••••••--•-------........----•.----....-•••••-••-----------------•••----•---•---...................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
-----------••-- • •..... •_..
n/� 's n
Application Approved By..... --- %���=------�r__ /Y _._._ : .. ......----(--- . ..... ..........
Date
Application Disapproved for the following reasolq.J -•------------------------------------------------------------------...................
....
-----....._...--
I.
- -------------------
.e
Permit No._ .... .... Issued..... l�
Date
..........................
ate �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1
jj. TQPIn.....................OF...Barnsta ble ..........
.......... ...........................................................
f
%1 I (Intgfirate oaf Toutpli anrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired j_%ti )
byJ,P.Macomber Jr.
Installer
°a.],7,a_( ......................."tr .R :rnt;�l?b?_
has been installed in accordance with the provisions of I'_1.m r. 5 { T State Sanitary Code as described in the
application for Disposal Works Construction Permit No _ �'".A-i �--_------- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................... .' ------------------------ Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. ...........................................OF........-----•--.................... .�...........................................
U! f 1()
. No..�. .............. FEES..�fix..........
1•
Otspos al Vorkii 0annntrnr$ion rranit
Permission is hereby granted_..,s_w .'ict r;t-iR;ni.r -T' .a X y.....••---•-----••----•••••-•----•---•••--••-------•••-••••-•--•----•..................•.....
to Construct ( ) or Repair an Individual Sewage Disposal System
at No...r°'2 Mkt!I "i??..s�'Lt' -'t lest Barnsto;;11e
...............•----••.. --•---_ ---------- �----•--
Street
as shown on the application for Disposal Works Construction Viermit N .. __... 2 ated..... _. _ •• •_
rAl-V�..- •.• t.. ___
7//' Board ealth
DATE
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
TOWN OF BARNSTABLE ✓
LO(;'ATION (1V� Or) t �7 SEWAGE # Z7 - 6
VILLAGE W s �y � �� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. V40k,-r-
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) ✓� ® Y�
NO. OF BEDROOMS t
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
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
1. within 300 feet of leaching facility) Feet
Furnished by
3 Zm
8 3VIC-
�'
41 g0
T