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HomeMy WebLinkAbout0575 WILLOW STREET - Health 575 Willow StRE� West Barnstable A = 130 - 036 i TOWN OF BARNSTABLE LOCATION US W;Ao lJ S I SEWAGE#C261$ �/ VILLAGEE r►&Jble All ASSESSOR'S MAP \\&PARCEL INSTALLER'S NAME&PHONE NO.Te 11134,2^712 7 SEPTIC TANK CAPACITY 1OW qa "� LEACHING FACILITY:(type)2/� . 1 µ 2e cl o mb (size) JAri ;T NO. OF BEDROOMS OWNER Patric K Com K Lin PERMIT DATE: COMPLIANCE DATE: GS/ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY NOUiE 3 l�0 13o a 14 Iz3 ►3S 5 Itive - TOWN OF BARNSTABLE LOCATION 975 W l tL O w CT SEWAGE # I�LLAGE W 25T ? K N ST A-&i-C- ASSESSOR'S MAP & LOT 130136 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY tOOO moll LEACHING FACILITY: (type) (size) Fo0 yp o DW- 10 NO. OF BEDROOMS ' BUILDER OR OWNER M P R G (-XGT * LOR I* -JO N WSOq PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S® Feet Private Water Supply Well and Leaching Facility (If any wells exist ®6 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 LCo - 7NCH kmviRozv MlZwr k1- - SN15PL-CTi01J rr, 0 UTILITY LLJ LOCATPONS POLE W 1y A B 1 �- 1 70 FE 91.5 FE (n 2 78 FE 84 FE 3 89 FE 71 FE LEACH LEACH O PIT O PIT O ' ❑ o-eox J 2 J o SEPTIC TANK u i EXISTING WELL - OVER DWELLING ...100 FEET TO SAS. NOT TO SCAU ru .. • na 0 cc .Z- -4 q3 Certified Mail Fee C Extra Services&Fees(check box,add fee as appropnate) p i,�NItR ❑Return Receipt(hardcopy) $ N UA1 . `2003 P O ❑Return Receipt(electronic) $ Postmark �. O .[]Certified Mail Restricted Delivery $ Here ❑Adult Signature Required $ []Adult Signature Restricted Delivery$ t O Postage — - - -— — - - - - - - m $ Total Poste $ CONKLIN, PATRICK H & MARY J Ln Sent To 575 WILLOW STREET C3 WEST BARNSTABLE, MA 02668 City-Sfate;, �' :.. r r r rrr•r• Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service'" Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent Important Reminders: Adult signature service,which requires the w o You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). Priority MOO service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified; ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent. with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,R should bear a certain Priority Mail items: USPS postmark.If you would like a postmark on-" ■For an additional fee,and with a proper this Certified Mail receipt,please present your -� endorsement on the mailpiece;you may request Certified Mail item at a Post Office"for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Retum Recelpt attach PS Form 3811 to your mailpiece; IMPORTANT.Save this recelpt for your records. Ps Form 3800,April 2015(Reverse)PSN 7530-02-OOo-9047 o Complete iterris 1,2,and 3. Oire ® Print your name and address on the reverse X ❑Agent so that we can return the card to you. ❑Addressee ■ Attach this card to the back of the mailpiece, B.Aceived by(Pr?VjX0J1L- Ne) C. Date of Delivery or on the front if space permits. D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No CONKLIN, PATRICK H & MARY J 575.WILLOW STREET WEST BARNSTABLE, MA 02668 o. Service Type ❑Priority Mail Express® ❑Adult Signature ❑Registered MallT"+ II I III IDI 9I I II II II I I III I I�III�I)II I I I ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted 9590 9402 1933 6123 1777 60 $Certified MaH0 euv.ery Certified Mail Restricted Delivery etu Receipt for ❑Collect on Delivery Merchandise I ;—�N�i n�.=„i,�r ITiansfer_from servtCe/abeO ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationTm k' t r = = s` ;4;;'"til ❑Signature Confirmation I 710 15,t 17 3 0 .GO 01?=4`9 8'8 {�312 �'}f t iil Restricted Delivery. Restricted Delivery • I PS Form 3811,July 2015R17s39f .Dt3EQS3 ii��ttttlil�;ltl � ; I 1 USPS TR-A`, � .- '"' `' First-Class Mail q r Postage&Fees Paid USPS Permit No.G-10 9590 9402 1933 6123 1777 60 United States •Sender:Please print your name,address,and ZIP+4®in this box• i Postal Service � I I I s'wq Town of Barnstable Health Division 200 Main Street Hyannis,MA 02601 I I I I I I I I i �oF twE rp� Town of Barnstable Barnstable Regulatory % Re ulato ' Services Department AMmedcaCRl PnseLF. 1 1 9 ,� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0312 May 8, 2018 CONKLIN, PATRICK H & MARY J 575 WILLOW STREET WEST BARNSTABLE, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 575 Willow Street, West Barnstable, MA was inspected on 04/12/2018 by Nicholas Geneseo, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Leaching system has failed. Pit 41 was crushed and filled. Pit#2 is overfull and is running back to the distribution box. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH c ean, R:S., Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\575 Willow Street West Barnstable.doc THE r, . Town of Barnstable - 1 Aa RN�TIAi C i♦ Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA'02601 015ce: 508-8624644 Richard Sc4 Director FAX 508-790-6304 'Thomas A-McKean,CEO Feb 6, 2007 Rev. 5111116 DEADLINES TO'REPAIR FAMED-SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ 'An`Z'marked in the ❑is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. :. o Backup of sewage into the house due to an overloaded or clogged SASor cesspool ONE(1)YEAR DEADLINE CRITERIA tatic liquid level in the ' button. x above outlet invert due to an overloaded or clogged SAS or cesspool , ; / )v1 ' ❑Any portion of the SAS, cesspool, or privy below 1higroundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality,analysis '(This system passes if the water an indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Single'Cesspool ❑Any"conditio'nally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) G OTHER Repair deadline: _ wsEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - n» 575 Willow Street Property Address +� Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 M/12/2018 page. City/Town State Zip Code ate of Inspection U1 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 A. General Information �/ aq filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Nicholas Geneseo use the return Name of Inspector key. Wind River Environmental � Company Name 46 Lizotte Drive Company Address Marlborough MA 01752 City/Town State Zip Code (973)830-6126 S113988 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 ` (-toll� 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 Srstteem•Page 1 of 17 /� VS Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 575 Willow Street M Property Address Patrick Conklin Owner Owner's Name informatics is required for every West Barnstable MA 02668 04/12/2018 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 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 day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 575 Willow Street Property Address Patrick Conklin Owner Owner's Name informatics is required for every West Barnstable MA 02668 04/12/2018 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 If 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 575 Willow Street Property Address Patrick Conklin Owrer Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 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? 0 ❑ 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 gpd t5ins.doc•rep'.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well 9 ( Y 9 (gp ))� Detail: Private Well Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M s 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is West Barnstable MA 02668 04/12/2018 regwred for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•red.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is West Barnstable MA 02668 04/12/2018 required for every 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: 1976 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 122 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Plumbing looks good with no leaks. Joints are solid. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'x5'x4' Sludge depth: 3" t5ins.doc•rep.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 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 27" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? The dimensions were determined by sludge judge, rod, and ruler. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The liquid level is at the outlet invert with both tees in place. The tank appears in good condition with no leaks. Recommend upgrading the tank with the system. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 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 1/4" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box has two outlets. Outlet 1 is blocked off because Pit 1 was filled in years ago. Outlet 2 has 1/4"of liquid in the pipe. The box has some carryover and some deterioration of walls. 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is requires for every West Barnstable MA 02668 04/12/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 @ 6'x 6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The system had two pits but Pit 1 was crushed and filled. Pit 2 is overfull and is running back to the distribution box.The system is in hydraulic failure. 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 r Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 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 ^M 'y 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 page. Cityrfown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately U a 00 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 575 Willow Street Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: TBD 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: To be determined at time of new system design. 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 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 575 Willow St-eet Property Address Patrick Conklin Owner Owner's Name information is required for every West Barnstable MA 02668 04/12/2018 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 ® Sketc-i 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 r 3/2372O18 AsBuilt ivrviv yr nniuvalrwLZ LOCATION S 75 W l G L D w ST SEWAGE a VILLAGE WEST R K—NSTAgL6 ASSESSOR'S MAP&LOT 130 3fo INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACrrY tQDO �t�/ LEACHING FAC1LrN: (type) +S C (size)Z size RO'ID ND D NO.OF BEDROOMS BUILDER OR OWNER M R G�'fzt<7 LDR 1 t�X� O SOLI PERMUDATE: COMPLLANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 130 Feet Private Water Supply Well and Leaching Facility (If any wells exist 100 + on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist (Q p t within 300 feet of leaching facility) Feet Furnished by IRco - ?�(k i<�,tvtRo tv'lvs�►�t'R L — XW2 G ECT O 1.1 e LJ LOCAVONS . OPOL�E Y LLJ ry A 8 1 70FL 91.5FL Ln 2 78 FL 84 FE 3 89 FL 71 FL LEACH LEACH O PIT O PIT O T J 0 o•BOx 3 . SET TIC A EXISTING WELL -OVER DWELLING *0 FEET TO sns. NOT TO SCAL ,1 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=130036&seq=2 1/2 1 down cape engineering, incSIEVE SOILS ANALYSIS 575 WILLOW STREET W. BARNSTABLE, MA DATE OF REPORT: 6/4/18 .JOB : GRAIN SIZE ANALYSIS-SIEVE TEST SITE: 575 WILLOW STREET, WEST ABRNSTABLE LOCATION: GLEN HARRINGTON TEST HOLE SIEVE ANALYSIS Weight Sample(Grams): 150.1 1SIZE :WEIGHT RETAINED % RETAINED %PASSED ------------ .............(sum.. .........................---------------- .................. 1" ................ 3/411 0.01 0.0% 100.0% ....................................................... --------- o - --------- ° 100.0/0 3/811 0:0'::_ _-_--0.0%i: 100.0% ------------- :............................................. -------- ° j---------------o- #4 0.0 0.0/0i 100.0% --------------......................................................y-------------------- ..................................... #10 6.3f 4.2% 95.8% •--------------.....................................................------------------o-...................... °............. #20 25.8 17.2/o: 82.8/o -------------......................................................y--------------------4........... ................. ..... #40 ............... ..............I............66.3 ----44_2%=..: #50 , 94.1 62.7%€ 37.3% -------------......................................................y-------------------y......I............................... #80 127.41 84.9%€ 15.1% ------------ .................................................. ...:---------------------.................................:.. #100 135.9' 90.5%: 9.5% --------------'s.......................................................-------------------- ------------------ #200 147.2' 98.1%' 1.9% -------------:......................................................:--------------------_----- PAN: 148.91 100.0% r0.0% SAMPLE: 150.1 i NOTE:TEST ON PASSING#4 ONLY, 1.8% RETAINED ON#4<45%O.K. RESULTS: SOIL CLASSIFIED AS AASHTO A-3(FINE SAND)(UNCOMPACTED) PERCENTAGE OF MATERIAL PASSING#4 SIEVE : #4 100% (TEST ONLY MATERIAL PASSING#4) OK #50100/6400% OK #100 0"/6-20% OK #200 0%-5% OK SAMPLE MEETS TITLE 5 FILL SPECIFICATION >98%SAND RESULTS: PERMEABLE MATERIAL-CLASS 1<2 MIN.AN. MATERIAL NONCOMPACTED SOIL DESCRIPTION: FINE SAND ��tioFr��sS* DAN14A.' yes o; O. LA �+ CIVIL ,�.: No.46502 ��_c_ ,� Town of Barnstable P#j 5-In. Departinent of Regulatory Services 8 sru�NarAsf�4 Public Health Division Date 1 M AIM r i'd3 200 Main Street,Hyannis MA 02601 t?„5 En h1Kt r� Date Scheduled Tim , e Fee Pd._�b V: Sort Suitability Assessment for S /, age Disposal `l 4h Performed-By: �� a 1,1 f4�7M� �s�i Witnessed By: LOCATION&.GENERAL INFORMATION Locatlon Address Owner's Name /' GIST�ff2tJ 5 7t}/3 L 2 � Address S T Assessor's Map/Parcel: • f 3 0/3 6 Engineer's Name y ' NEW CONSTRUCTION REPAIR /� Telephone IF �7 y- a 36 i�13• . Land Use All( Jr—P 'H. Slopes M --S Surfhco Stones_ Distancoa flrom: Open Water Body---> z�� ft Possible Wet Area 7yU71 ft Drinking Vlfatcr Wcll �ft Dtnlhago Way ft Property Line d ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test bolos&poro tests,locate wetlands-in proximity to holes) 1 25.0 - - I 258.0a �1 *I LOT 8 a NJ AREA=1.66t Ac. • , I .............. 1 0 s sPA A-21.55• R-25.0 Parent material(gcologic) DYAiI�� Depthtppedroak > Depth to Oroundwater. Standing Water In Hole: Weeping from Pit Fnoa -4r a ki'e Estimated Seasonal High Groundwater > 1,7Z5 r DETENA ON FOR SEASONAL'I�GH WATER TABLE Method Used: S 0 r t�R .4 > �S® De th Observed standing In obs.hole: _ _- In, Depth to Soil mottles: Dzth to weeping from side of obs.hold: _ In, Groundwater Adjustment ft. index Wcll-# Reading bAto:- Index Wall level Ad 4hator„•„„_,_Adj.Groundwatdil-Laval,._ PERCOLATION TEST Date . 71me_____ Observation Hato# Time at 9" ..,, Depth of Peru Time At 6" Start Pro-soak Time @ Time(9"41 End Pro-soak �f e �t ..04��F^'trj( 0�vw C.? , Rate Min./Inch , Site Sultabillty Assessment Sitd Passed Sitp Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on B ack---- ' ***If percolation test is to be conducted within 1001 of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Solt Horizon Soil Texture Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnuctum,Stoner;Boulders. y ' tsistency. A %CI►avall Z w L3 to, Y 2 5'/G .vn. fo Z l,"v C 71 W, k-.Od Z,S—y 7 y .t-d DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Sail Texture Sall Color Sall Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. 7,4 vh f44qe Zt,5- IL t N� DEEP OBSERVATION HOLE LOG Hole# Depth from, Soil Horizon Soil Texture Sall Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. DEEP OBSERVATION HOLE LOG Hole# Depth from Soli Horizon Soil Texture Sall Color Sall Other Surface(in.) (USDA) (Munsell) Mottling ' (Structure,Stones;Boulders, Consistency, Onlyll) Flood Insurance Rate Man: Above 500 year Mood boundary No— Yes . Within 500 year boundary No_! Yes Within 100 year flood boundary No.-m— Yds penth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring parvioua m itertal exist in all areas observed thrpughout the area proposed for the soil absorptibn system? If not,what Is the depth of naturally occurring pervious material? ...�.. Certification I certify that on `d l (date)I havo pass e'd the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with , the required trai ing,expertrex enca described In 410 CMR 15.017. Signatur Datb / 711 Q:%aHPTlCWR1tCPORM.DOC No. b Fee 100 • Oa THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y—ate PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es applitation for Disposal *pstem COITBtCUttion Permit Application for a Permit to Construct( ) Repair(v� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 5'IS V 1LI.p Owner's Name,Address,and Tel.No.`O wrsT0AZW.>rVreL$ N^f 0=&0o 17R1Ll GONhL%N 9`-j$ W1\10vV Assessor's Map/Parcel 130/3 to wr A 1 e (3 Sr gA¢ t ate, A. O.,;Lbto Installer's Name,Address,and Tel.No.Throrho_S �xVWA esigner's Name,Address,and Tel.No. 4LUN A ARRWN(9 t-1 S 11 W 111 oc� l-rr s ,e-AL - (,Sob-3b� Y. -j n-17 01 1_%0A R LA�r ose E -thy- �3�- ►%13) W- mPtR_sTvKS M t L1.5 i 1'v1 pi O;k.(p4 W Type of Building: Dwelling No.of Bedrooms 2.. Lot Size 7 al '304) sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Z►Z.0 gpd Design flow provided 3S6 gpd Plan Date (o ' 1 7.•01 4B Number of sheets 11. Revision Date Title Size of Septic Tank 1 000 Coo 1. N-10 Type of S.A.S(� otS, kw �{•Z� Description of Soil C 1 C.7- as 3 .x o�� W�i+� 5 -t'*►p OVf-, Nature of Repairs or Alterations(Answer when applicable) oIA • Date last inspected: 3 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 am t to place the system in operation until a Certificate of Compliance has been issued by this rd o th. ....... n Date I Zljl Application Approved by Date Application Disapproved by Date for the following reasons Permit No. F�7 O /Qj Date Issued 4 • 4 NoA ? .� 'l;� Fee ',1 00 ' 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes �ltlYication for Bisposal 6psfint-to-ustrULtion Vermit Application for a Permit t`Construct( ) Repair( ,)"`Uprade( ) Abandon( ) ❑Complete System ❑Individual Components p , _ Location Address or Lot No.-5.I5 W 1Li.(jW � Owner's Name,Address,and Tel.Now©9, L3 y4? W�T f:,.AGt.,•�;i-�Y!31.� , M:r+.. O��ntn . � • .;p,TT�IUti: c_..vNl-5L.i+�F 5'1S w t i l c��n.) t�'--��•T Assessor's Map/Parcel 13U/.3 tv !_,or: A ! AAA Installer's Name,Address,and Tel.No._rh0rnG S 1 a try Designer's Name,Address,and Tel.No.GLE N A AR lit N%,. rQ ` �SOb- 3t�_--111-1�`. -q L.�r�A Rose VA�sE �7��{- �3`6 ' 4$13> (t1. .�S x+�S i> �v1q O.�lotn x rv)A R_<_-> C�5 M%LLS � YWi A G�:x to-1 �S 1)rpe of Building: ____ .__._•.M • Dwelling No.of Bedrooms 2.. Lot Size ! , 3G sq.ft. Garbage Grinder( ) , Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow(min.required) gpd ` Design flow provided ?, d gpd Plan Date Number of sheets' '2 - Revision Date Title ! Size of Septic Tank i ��' W - ►0 Type of S.A. -42 5ao'Ova. Description of Soil C.1 l :' 3- �•5 • 13 >e oL, p cy� Nature of Repairs or Alterations(Answer when applicable) C71 Date last inspected: 3 ' 3-1- ;;�_CG K ' 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 snot to place the system in operation until a Certificate of Compliance has been issued by this isBoard pf Healt ____--.--- igAed .. ,r ( ...-""'�.'".--�"""' Date Application Approved by - Date Application Disapproved by Date for the following reasons Permit No. "' ~' _5 Date Issued /h-s /i` 'a � --=-------------------------------=-------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate.of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned b at 1 �t`f (�U i ilk - has been constructed in / } with the provisions of Title 5 and the for Disposal System Construction Permit No`�#1 7f� )6 5 d ted Installer y • Tn C. 'Tl'�c;r��a S "Tl E 1_a Designer �I•�, #bedrooms Z- Approved desigI ow A gpd The issuance of this permits all not be construed as a guarantee that the system wiC"functio as designed. i Date ��� Inspector �J No.,�:)G'/ 1 )SS Fee / 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Voposal *pstent Construction Permit' Permission is hereby granted to Construct( ) Repair o Upgrade( ) Abandon System located at 5-15 'yJ�\l C)uJ f ,, y and as described in the above Application for Disposal System Coma�nstruction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. s i Provided:Construction must be corm leted,within three years of the date of this permit. Date C� �' } Approved Bye._ S Town of Barnstable Re ulatory Services * . Scali,Interim Director * BARNSTABIZ MAB& ��� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Z�Z/�/g -� a Date: --f Sewage Permit# ��J�-jS$ Assessor's Map�Parcel 1? 6 Designer: 6la,,,,F. h(&r/ 0_t14 y, Installer: Mrh yenneLA Address: 9 L A Oft L H Address: tr-714VAw J7 Nl WesT Sarr�s/�t�lr. /�I A 6 ( ,&9 On / was issued a permit to install a (d e) (installer septic system at S*75- A/, /lw J�-,/ AV. Ar nIAA6 based on a design drawn by (address) �(rw► E', //0-r.ihJ�o✓�, R•S, dated t Z aP.,V 7,017. (designer) �I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out if required) was inspected and Pe soils were found satisfactory. f� e,� I certify that the septic system referenced above was installed with major changes-(i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to4ollow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constru ` 5 e with the terms of the IAA approval letters(if applicable) i HAMINGTO N (Installer's Signat Ii10.1070 0 ITA (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc Ion �� �" 7 � _ � � L r -- � � OF THE Tp� DATE: �O s FEE: * BARNSrABLE, « y Mass. qj 1639. `0� REC. BY Town of Barnstable SCHED. DATE: Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne A.Miller,M.D. FAX: 508-790-6304 Paul J.Canniff,D.M.D. VARIANCE REQUEST FORM LOCATION Property Address: 5-r- Ac- Z C c Assessor's Map and Parcel Number:-1 � -- U"� �^ Size of Lot: Wetlands Within 300 Ft. Yes V' Business Name: No Subdivision Name: APPLICANT'S NAME: Phone Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON Name: h O 1� (� ` P/ ® �hC 60_� Name: J�� 1 0 C rn t�ZA 5 c-J Address: tA Address: ':9 Phone: 9 $ d "S l Phone: Socg 4�4? ( ti`� VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) NATURE OF WORK: House Addition ❑❑❑❑❑❑ House Renovation ❑ Repair of Failed Septic System Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate completed sets. _ Four(4)copies of the completed variance request form _ Four(4)copies of engineered plan submitted(e.g.septic system plans) _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) _ Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/leasee only], outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne Miller,Chairman NOT APPROVED Paul J.Canniff,D.M.D. SEASON FOR DISAPPROVAL Q:\Application Forms\VARIREQ.DOC MAIL-IN REQUESTS Please mail the completed variance application form to the address below. Also include four copies of engineering plans, house plans, authorization letter, etc (see check-list below). In addition, please include the required fee amount (see fees at bottom of this page). Make $85.00 check payable to: Town of Barnstable. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 Checklist _ Four(4)copies of the completed variance request form _ Four(4)copies of engineered plan submitted(e.g.septic.system plans) _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) _ $85.00 variance request application fee(no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only], outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please`fax a completed application form. Also, you must mail the required $85.00 fee. Please make the check payable,to: Town of Barnstable. The check must be mailed to the address listed above. In addition, please mail four copies of engineered plans, house plans, authorization letter, etc. (see check-list below): Checklist Four(4)copies of engineered plan submitted(e.g.septic system plans) _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that.the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) _ $85.00 variance request application fee (no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only], outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date For further assistance on any item above, call (508) 862-4644 Back to Main Public Health Division Page r No.---Al V � �[/�� t ----- - --- Fee---- - --==�---- BOARD OF HEALTH TOWN OF BARNSTABLE ��' Application,for Well Construct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), SRepair n individual Well at: �%/ ;7- _-__---- -- --- - - � � _-_- -- ---- Location — Address Assessors Map and Parcel Owner Address -------- ---------------------------------------------------------------------------- Installer — Driller Address Type of Building Dwelling------------------------------------------------------------- Other - Type of Building ------ No. of Persons-----------------------------------_______ Type of Well "r ----- YF --�- ------------------- Capacity----------------------------------- Purpose of Well------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. 11 Signed — - - ------- — -----— ------------- date Application Approved By ----- ---- — ate ---- -- ----- GT Application Disapproved for the following reasons:--------------------------------------------------------------------- ----------------- —_—_ - - -- —-----— ------ - - - -- - - - -- - — -------- �t date Permit Nd!"-- —� -- t� Issued=S-—0-- v -------- --------- - ----------—------------------- date —— BOARD OF HEALTH TOWN OF BARNSTABLE Certificate (Of Compliance THIS ISS TO CERTIFY, That he Indiy)dual Well Constructed ( ), Altered ( ), or Repaired ( ) by -------- -------------- ------- / Installer at- -71`— ��1 � --�`�-- _ 1 - ��i1J, ------------------- ----------- ------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------------------------Dated------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------— - —---------— - - --- — —- Inspector---------------------------------------------------------------------- x F R No. Fee-----r-:.• ---^'---- D OF HEALTH TOWN OFARBARNSTABLE Application,for Vett Con$truct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), ,r�epairn individual Well at: : 0 3 -- ------ �.�. focation — Address Assessors Map and Parcel !---------— ----Owner Address _ ---------------------------------- Installer Driller Address Type of Building Dwelling-----—------------------------------------------------------ Other - Type of Building --- No. of Persons-------------------------------------- Type of Well- - - ----- -- -� Capacity ------ Purpose of Well Agreement: ---- - - - - --— ' The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of o he Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed ------------------ date �� Application Approved By--- --�---- -- -- �-�—----- __— _ � ------- --- ate --- Application Disapproved for the following reasons:------------------------_---------------_----------------------_____—___—_________ -----------= -- --- --- —---- ----—- ---- - - --- - - - - -- - — - - date Permit Nd!`I - -�--- yr- --— -- - Issued—S I-� ? G - - - - — -—- r date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CE�RrTIFY, That he Ind' 'dual Well Constructed ( ), Altered ( ), or Repairedby ( ) ---------------------------------------------------------------------------- Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ------------------------Dated------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------------------------------------------- - -- Inspector-------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ----------j BOARD OF HEALTH TOWN OF BARNSTABLE ` Melt Con$truct ion Permit No. �� QL -==� // Fee---a�--�-- Permission is hereby granted_ S_ C C,,nQ (1 ---------- -- to Construct ( ), Alter ( ), or Repair( Individual Well at: No. ----------------------- -- -— ----- -- ----------------------------------- ------------------------------------------------------------- ------------------- Street as shown on the application for a Well Construction Permit No. ----------------------------- - ------------------------------------------- D(t6d �z-------------------------------------------------------- C---------------------- Board of Health DATE— - -� -- -- -- — - i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is required for ry West Barnstable MA 02668 January 10, 2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information �4 When filling out �-� forms on the computer, use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental _ Company Name Q 43 Triangle Circle Company Address Sandwich MA 02563 �eavn City/Town State Zip Code 508 364-0894 Pending 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:15.34Q of Title 5 (310 CMR 15.000). The system: C— _,7„ ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 's ="^' }� v E January 10, 2007 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2527.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is required for West Barnstable MA 02668 January10, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2527.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is required for West Barnstable MA 02668 January10 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 1:5-2527.do�•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is required for West Barn January stable MA 02668 J 10 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: .* II This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ® than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-2527.do�•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is West Barns January table MA 02666 J 10 2007 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. I t5-2527.do;•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 I I Commonwealth of Massachusetts w Title 5 Official Inspection Form- _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is required for west Barnstable MA 02668 January10, 2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ N/A 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)] t5-2527.do:•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is West Barnstable MA 02668 January 10 2007 required for , every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a—well in use 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: May, 2006 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day d P Y(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2527.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is ry West Barnstable MA 02668 January 10 2007 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, 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): I Approximate age of all components, date installed (if known) and source of information: Age: 29+years. Disposal Works Permit issued 4131177(Board of Health permit# 77-162) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2527.dcc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is West Barnstable MA 02668 January 10 2007 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): Depth below grade: 1.5 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: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 0 in Distance from top P of scum to to of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle _ 14 in How were dimensions determined? Permit application t5-2527.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is required for West Barnstable MA 02668 January 10 2007 every page. Cityi-rown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): I � i t5-2527.dcc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is required for West Barnstable MA 02668 January10 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.).- Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Distribution appears to favor one pit. I Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2527.dcc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is required for West Barnstable MA 02668 January10, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching pits appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down loudly. t5-2527,doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is required fcr West Barns January table MA 02668 J 10, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2527.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 575 Willow Street Property Address Margaret and Loring Johnson Owner Owner's Name information is West Barnstable MA 02666 January 10 2007 required for rY every page. City/Town 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. a UTILITY W LOCATIONS POLE W ry A B 1 70 FL 91.5 fL (� 2 78 f E 84 FL 3 89 fE 71 FE LEACH LEACH OPIT O PIT O 3 o D-130X 2 o f—i SEPTIC I TANK o 1 EXISTING WELL - OVER DWELLING tee FEET TO SAS. NOT TO SCALE t5-2527.dcc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 575 Willow Street Property Address Margaret and Loring Johnson Owner Owm*r's Name information is ry West Barnstable MA 02668 January 10 2007 required fcr , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check'Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 50+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: GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is 50 feet above groundwater table. f t5-2527.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 �' No.—�_------�.� :. Fee------:----- -------- BOARD OF HEALTH TOWN OF BARNSTABLE �r � App[icat ion for Very Construct ion Permit P )3v - Application is hereby a for a perfnit to Constru t ( ), Alter ( ), or Repair (mat individual Well at: Ad 0 Location — Address r Assessors Map and Parcel Owner Address Installer — Driller Address — — Type of Building Dwelling - Other - Type of Building ---- No. of Persons-------- ----- — -- i Type of Well ----- Capacity ---------- ---- Purpose of Well-----fit)U — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed >� — - `� daatete= q Application Approved By e -_—__-- /_0z --- date Application Disapproved for the following reasons: ----------------------- ---- —__------------__--------- date— —_ Permit No. V` ao'6 P 0 — - --- _1 Issued—�_7_d 6 ---------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (c;_ Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Weil P otection Regulation as described in the application for Well Construction Permit No.WAOX —01 Dated I ---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- - Inspector----------------- ---------- Fee­ No. ------_-- ----------- R BOARD OF HEALTH / TOWN OF . BARNSTABLE ('� - Applicat ion-for Vell Contructionperntit Application is hereby adew for a pe it to Construct ( ), Alter ( ), or Repair(than individual Well at: Location — Address r Assessors Map and Parcel Owner Address . . Installer — Driller Address Type of Building Dwelling 's - Other - Type of Building--=---------- No. of Persons- Type of Well y -- —_—__— Capacity---------------—---- —_- Purpose of Well- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed date Application Approved By ----- /- /ai-0,6 __ date Application Disapproved for the following reasons: ------ ---- -- _ — __---------- date -- Permit No. -i/'Q OOG .o_t — Issued - _a G`' date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (c-) by Installer �----------_— ---_- at— has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private We 1 P otection Regulation as described in the application for Well Construction Permit No.�i- Dated! h U -------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- - Inspector--------------_ —_---____ BOARD OF HEALTH TOWN OF BARNSTABLE 1Vr1l Co' n!5truct ion Permit No. -� U o - 0' Fee Permission is hereby granted — - ---------to Construct ( ), Alter ( ), or R pair ) an Individual Well at: No. --'� Street as shown on the application for a Well Construction Permit I / 6 l No.- .— Dated � _._.— ---------------------------- - - ---------------------- DATE l Board of - � ! �� No..... .(.�— FEE........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 3 OF......................................................................................... ®� b Appliration -for BOVviitt1 Worko Tow3undion Vrruift Application is hereby'made for a Permit to Construct ( )) or Repair ( ) -an Individual.Sewage Disposal System a ..................................... ..................... 6.......................................... cation-Ad s of f --------------•--------------------- -•------------c %G '. er rA W -- -•------ /!-�f�C .f.�/. j Installer Address d Type uil tng Size Lot_-/!----_-__-_- ___-Sq. feet U Dwelling—No. of Bedrooms._-__-__ _.._ Expansion Attic ' Garbage Grinder - aOther—Type of Building --_. _ No. of persons....... -•_______________ Showers (/) — Cafeteria ( ) QOther fixtures ---------- - ----------------------------------------------------------- --------------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity VO-gallons Length---------------- Width................ Diameter................ Depth---------------- x Disposal Trench—No_ ____________________ Widtli.__. __.___.._____. 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------------ 307 --.. Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water_..._-.._-.----.--.--.-- G= Test Pit No. 2________________minutes per inch Depth of Test Pit..................... Depth to ground water.......-._-__-.--__-__-- ax' ------------------------ --•-•••...-- -------------••-----•-••......•••• ---- .......... -------- -----y .escr Description of Soil------------C [ l -Y - t�•-.--• -__ -------- ----------------- ---- 00, �LL_t:_....._.. !�ST Get r/ - / /6. �i. -------•........... Q Y C r x /--/t V Nature of Repairs or Alterations—Answer when applicable.......... __________ �`----T�__::.._.___.-- .............................---------------- --------------------------------------------- -------------------------------------------------•---------------------- / ------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article LI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is d by the toard of healt .- L Signed.--- �•- .....A .. . •• �Y ........... Date i Application Approved By------ -----•-------•--- -----------•--•------•--- ----•--------------- ' Date Application Disapproved for he following reasons:----------------------------=--------------------------------------------------------------- ..--•------•••-- Date Permit No.__._ �. Issued.........f�__.__-�-�. -------------------------•----'---•--•--• Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ... ..................OF...........................:...:..... ... Applirtttion -for BiBpoiial Workil Tote#rurtinn Vamit Arprkation is hereby"made for a Permit to Construct ( ) :or Repair ) an Individual Awnuisposal System; .. .•. --------------•- ----- cation Ad e - .�„ o Lot �. ............................... .............. .............. -- -- ....._.. er s dress W i.. . ....................... ........ ...... ... ' Installer Address "� � /). Q Type Buil mg Size Lot:__ .—Sq. feet U Dwelling—No. of Bedrooms..._ Attic 0(000'r Garbage Grinder ( ) Other—Type of Building . � No. of persons------ -------•---------- Showers ( ) Cafeteria ( ) Otherfixtures -------------------------------------------------------------------------------------------------------------- - -- ------------- W" s Design Flow..............................................gallons per person per day Total daily flow.......................... gallons. WSeptic Tc.nk—Liquid capacity/ _-gallons Length---------------- Width................ Diameter.___'_" :.Depth------------_-- Disposal Trench—No........... Width.. ............... Total Length Total leaching area -. s ft. Seepage Pit No------- ___-___ Diameter ...... ... Depth below inlet.................... Total leaching trel_ � -sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................._...___..____..._.......__._.._.____._.._ .. Date.. ------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground ,waters..................... (L Test Pit No. 2................minutes per inch Depth of Test Pit---_---------------- Depth to ground',water__._.-_---_--__-____---- ------------------------- ----------------------------------------------------------------------------- -- D Description of Sot F'- --- ------------ ---- , ._.t__l�__s?4tnw.s� lull P------------------- ---- � ,-- - --cow'-s`� ---�it+�-`v r �v VNature of Repairs or AlteraTions Answer when applicable_-_-__. ,?� T -- Agreement: I IS The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systetn in accordance with the provisions of Article XI of the,St ek,§ �itary Code— The undersigned further agrees;not tc � � ce,h is s em in operation until a�Certipicate ofotnplince;haJ�ei�`i d by the o4rc1 of helt 4 � J r� >r w J 4.. s � �/ Date Application Approved B --..lr................•----- • ............................................. 4 Date Application Disapproved or the following reasons____________________________ .................•------•----•-•----.....-•-----------------•-•------------------------•-•-•-••---------------------------------•--•------------ -.----.--..--_.--_---•--------------------•----- Date PermitN A/--•--------•----•------------------------------- Issued. ................................ Date THE COMMONWEALTH OF MASSACHUSETTS: BOARD OF HEALTH !r" Oy d .. .. ............ ........OF. .... 04 ,y k. T t� l �prfifirtt#r of o40 mphaure � ,-,,{�.. 4 TH I T CERTI Y That the I4tlividual Sewage Disposal System constructed ( or Repdr'ii�ed,- • �ss � '.. � �k« Installer lye/v' /l �5 a�,v �• 7 has been installed in accordance with the10-1isions of :Article XI of The State S� ary Code as described in the I° application for Disposa Morks Construction PermitY LL Flo./-(a_., ,-_________________________ dated _ y; 1 4 i r'r THE ISSUANCE OFj`T'F9 11'IS CERT4F;CAYS ;LG.N`OT BE CONSTRUED AStl4 kiV i,IA Tt1E1 ;. -SYSTEM WILL FUNCT(,ON SATISFACTORY. DATE•- t- ,� ... ---- nspector ----•- . i1v THE COMMONWEALTH OF `MASSACHUSETTS c� BOARD Of (HEALTH .. . ...OF--: ......... x r tg 1r. ....�............................. No.--•---. --- FEE............... Permission is hereby granted 'r----- ---------•----.----- -.......: -•------ ----- -------------.----_---------------------• - -r to Construct or R . air ( ark` c�v u�l"Sewage DLs$,o at No-----------E6 "! - --- as shown qt-'t„he application for D4.621 /orks Constructi;n1*96i� No--------- _ D" d__________ ____ ________ ________ /, �' • �� r YJI Board of He ;r1 DATE.......-•-................. ------ ON a PUB �H' ERS1255 FORM - R s•R'3F' , j. id s`�•m-#ut ':- 'v'ar... µ� w :`.ti:�E J .tc - Ju``. rTr k? � ,N' 4... J.