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Home My WebLink About0050 ACRE HILL ROAD - Health 50 Acre Hill Road , — �3a�n � f MEMORANDUM DATE: December 9, 2015 TO: Ian O'Connell FROM: Thomas McKean RE: 50 Acre Hill, Barnstable The Barnstable Health Division received a"Pass" Title V Inspection Report dated 11/19/15 and an inspection date of 10/29/15 regarding 50 Acre Hill Road, Barnstable. The septic system passes inspection. Thank you, Tom McKean I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rr 50 Acre Hill Road1 Property Address Margaret Hill,Jack Hill and Ann Hill Owner Owner's Name g_r, information is Barnstable MA 02630 10/29/15 required for every •� B page. Cityrrown State Zip Code Date of Inspection ;X4 Z, Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Mike Hudson use the return Name of Inspector key. Septic-wiz Environmental Services r� Company Name 28 Cape Cod Lane Company Address Barnstable MA 02630 Citylrown State Zip Code 508-367-5669 DEP SI#4254 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 yEvaluafin bythe Local Approving Authority 11/19/15 Inspector' ignature. Date The s tern inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 , , T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road " Property Address Margaret Hill, Jack Hill and Ann Hill Owner Owners Name information is required for every Barnstable MA 02630 10/29/15 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: f� ❑ 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): **"The septic tank and(1)6'x6'leach pit are under the driveway. Home owner has placed rail road ties to prevent parking over system components. This was observed at time of the inspection. I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill, Jack Hill and Ann Hill Owner Owners Name information is required for every Barnstable MA 02630 10/29/15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) (:1 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•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill, Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill,Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s . Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the ` questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 Acre Hill Road Property Address Margaret Hill,Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"non as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill, Jack Hill and Ann Hill Owner Owners Name information is required for every Barnstable MA 02630 10/29/15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 3 Bedroom Cape L 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 2013-241 GPD g ( y g (gp ))' 2014-274 GIRD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill, Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) �^ Last date of occupancy/use: y CC.uo%4L C S�1e Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: - N/A Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r~a 50 Acre Hill Road Property Address Margaret Hill, Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank and 1st pit same age as the house, 2"d 6x6 pit added in 1997, Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1 Depth below grade: 3'4rifeet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): vented thru roof, no leaks Septic Tank(locate on site plan): Depth below grade: 28"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 4'10"Wx8'5"Lx5'8"H- 1000 gallon Sludge depth: 4'10"(2"thickness) t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill, Jack Hill and Ann Hill Owner Owners Name information is Barnstable MA 02630 10/29/15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 1811 .How were dimensions determined? sludge prove, snake camera. LED fl000dlight and tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Pump every 36 months, inlet and outlet concrete baffles in good condition,tank structurally sound, liquid level even w/outlet, no signs of leaks. f J� 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•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill,Jack Hill and Ann Hill Owner Owner's Name information is Barnstable MA 02630 10/29/15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No. Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 it Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill, Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) (� n Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): IPump 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill,Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (2)6'x6'radius ❑ 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.): med sand to fine sand, no signs of hydraulic failure, no ponding, damp soil or abnormally lush vegetation, bottom of SAS approximately 13'below grade. (2)6'x6'comcrete leach pits. 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•3/13 Title 5 Offidal Inspeclion form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill,Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page, Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): �I 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•3/13 Title 5 Offidal Inspecton 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 50 Acre Hill Road Property Address Margaret Hill,Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately II _J t , t5ins-3/13 G Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill,Jack Hill and Ann Hill Owner Owner's Name information is required for every Barnstable MA 02630 10/29/15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water N A ® Check cellar N I A ® Shallow wells iN 1 .0 Estimated depth to high ground water: 301+ 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: Reviewed as-built/perc test ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Reviewed USGS water resource and topographic maps You must describe how you established the high ground water elevation: Reviewed USGS topographic and water resource map. Bottom of SAS is 13'below grade. Estimated high water 30'+ below grade. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Acre Hill Road Property Address Margaret Hill, Jack Hill and Ann Hill Owner Owners Name information is required for every Barnstable MA 02630 10/29/15 page. Cityffown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn'on page 15 or attached in separate file r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 SEP-10-03 WED 8:49 AM P. 13 5,elt ' O I i x i t f 7 N A? i r r t t i f 1 I i SEP-10-03 WED 8:48 AM Page 10 of 11 t OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i i Property Address; 50 Acre Bill Road,Barnstable 3 Owner: Hal Siegel Date of Inspection: June 14,2003 i 1 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. 03r 1 D V-IK t 1 j O I 4 zco f E 50 i Y 7 { 4 1A [ S IME o� 'Town of Barnstable Barnstable Y BARNSPABLE, ' 1edcacft MASS. Board of Health �m ArED rrtP�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 FAX: 508-790-6304 October 2,2012 Adopted October 9,2012 Public and Environmental Health Program Policies,Procedures, and Guidelines H-10 Components Discovered Beneath Parking Areas and Driveways During Septic System Inspections Conducted Under 310 CMR 15.301, State Environmental Code,Title 5 No. 2012-005 When a DEP certified inspector discovers an H-10 septic system component located beneath a parking area or driveway during a septic system inspection, conducted under 310 CMR 15.301 State Environmental Code Title 5, the system shall be deemed as a "conditional pass." The system owner will then be ordered,by the Board of Health, to correct this problem within two (2) years and will be provided several options to rectify the issue, including by: a.) replacing the septic system component with a new component relocated into another area of land which is not beneath any parking area or driveway, and properly abandoning the discovered H-10 component, or by b.) replacing the septic system component with an H-20 component beneath the parking area or driveway, and properly abandoning the discovered H-10 component, or by c.) relocating the parking area or driveway in such a way that no vehicle will have access or the ability to drive over the existing H-10 septic system component. If it is unknown whether or not a particular system component which is located beneath a parking area or driveway, is H-10 or H-20 (for example: a leaching pit is located beneath a paved driveway without an accessible steel cover to grade and there are no records on file indicating whether the system component is H-10 or H-20), the system shall also be deemed as a "conditional pass". In this case, the seller must make the potential buyer(s) aware of the "conditional pass" status, the unknown construction of the septic system component(s), and it's safety concerns. Wayne Miller,M.D. Paul Canniff,D.M.D. Junichi Sawayanagi Q:\POLICIES\H I OComponentsDiscoveredBEneathDrivewaysandParkingAreas.doc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m W DEPARTMENT OF ENVIRONMENTAL PROTECTION d w h R�CEiV�® JUL 1 1 2003 TITLE 5 HE ALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTAR SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 50 Acre Hill Road MAR Barnstable MA 02630 Owner's Name: Hal Siegel PARCEL Owner's Address: Same LOT _ Date of Inspection: June 14,2003 Name of inspector: PATRICK M. O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: (508)428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: (o O 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. Notes and Comments: System in good condition. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 Acre Hill Road,Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ 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. 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 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: r Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 Acre Hill Road,Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 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. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'". Method used to determine distance *'"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria arc triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 Acre Hill Road, Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool — X— q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or — cesspool _X_ Liquid depth in cesspool is less than 6 below invert or available volume is less than /z day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. —X Any portion of a cesspool or privy is within a Zone i of a public well. _ _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma No_(Yes/No)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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — — the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply — — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system 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. A I� Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 Acre Hill Road,Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ — Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection'? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out'? X Were all system components,excluding the SAS,located on site? _X_ _ 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 ? _X _ 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: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. X_ _ 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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 Acre Hill Road,Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 219,000 gals.For two years=300 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Last pumped 11/99 Source of information: Homeowner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:___gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Tank and pit same age as house,expansion pit 7/11/97 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Acre Hill Road,Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 BUILDING SEWER: X (locate on site plan) Depth below grade: 16" Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 40' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 18" Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8' long x 5.2'wide—1000 gal. Sludge depth: 7" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness: 4" 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: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Baffles intact and liquid level at bottom of outlet pipe. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Acre Hill Road,Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: No (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I Page 9 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Acre Hill Road,Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: 2—6x6(1000 gal.)in series. 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.): Pit#1 structurally sound liquid level at bottom of outlet give with no evidence of backup.Pit#2 has no excessive vegetation or ponding. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, lever of ponding,condition of vegetation,etc.): n f Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Acre Hill Road,Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 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. Wl5 �Ilo 0 I Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Acre Hill Road,Barnstable Owner: Hal Siegel Date of Inspection: June 14,2003 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 70 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: 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) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.30 for this property and USGS Hyannis quadrangle map shows land elevation at or above 100. „ I 2 9'7 063 No.... FRs..... .?(3...... I' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Divjipuial Worbi C ouBtrurtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (04 an Individual Sewage Disposal System at: Wa = __-A�Y-�--}-r ---- dress -s_ dress or-Lot--No . L-G�s L SQ Lu _-----------------------------------------•_---- -------- - -_ .................. -. -----t---- 1V1 c -s'1 l,? r � O � �.S% 1ca- o?. NCsw�z�3`�-- ............ ls- --------- -____• - --- . - Installer Address ,� d Type of Building Size Lot.....�4V� Sq. feet Dwelling— No. of Bedrooms___________________ __-_-.____.__---Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons--------_-.----____---- ___ Showers ( ) — Cafeteria ( ) a' Other fixtures _. W Design Flow.................... _.__._..____...gallons per person per day. Total daily flow----------------......___.. -��.�....._.__...____...__gallons. WSeptic Tank—Liquid capacity---gallons Length---------------- Width--.--.-___._.._ Diameter_..-.--_--- __ Depth................ x Disposal Trench—No. .................... Width____..._-__._-_-__- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------,1..._.... Diameter--------- ._._. Depth below inlet____ ___ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) ►" Percolation Test Results Performed by.......................................................................... Date..................................... �--4� Test Pit No. 1________________minutes per inch Depth of Test Pit_----------------- Depth to ground water........................ L% Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 04 ----------------------------------------•-----...._._...-----------------------------••••-•--•--••-•......................................................... 0 Description of Soil--------------------------------------------------------------------------------------- -----------------------•---------------------------------------•-•••--•-•-••--. x x ----------------------------------------------------------------------------------------------=----------------------------- ----- ------------------- -- U Nature of Repairs or.Alterations—Answer when applicable---------- �_--.___ -_ � �.... ......................................+4l.E ._... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een • sued b theXd of health. ,�}--�— Sined -------------- - ......................................... ...... g y� Date Application.Approved By ------------------�.c.,, - - J ----• - --------------------.....---------------------------------. ------, Application Disapproved for the following reafonr- -------------- ------ ---------------------------------------------------------------------------------------------------- ... .............................................._...................----._.....------------------------- -----------------------.....---.........-------........------------------------------ ------------------------------------- Permit No. -----------1757- ..� 6----------- Issued ------------------ --- ..................................... ... Date 2 7 / 06,3 sue` • .�.-- No.--35-- -.�,' & Fps............0............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . TOWN OF BARNSTABLE ` Appliration for Di5pu3,41 Eurk.5 Tomitrurtiuu ramit Application isr hereby made for a Permit to Construct ( ) or Repair Q>< an Individual Sewage Disposal System at: -S-o AtA L E ------------------•---..------ ----•-----•-•----••---•-------------••------------ ----------.._.__..---------•------...------... �� Loa Ilion-address or Lot No. /� �---7 Owner Addr ss �I..�ST,Q c1 cam-.....J to t-ti1�aLFly`1 y� Address �--•---••---••--•--- ............. ............... Installer _ VType of Building Size Lot.....GI..-S¢....... -.-Sq. feet I-, Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons----------.................. Showers ( ) — Cafeteria ( ) d Other fixtures .. •---------- ----------------- W Design Flow..................... ...- -----__._gallons per person per day. Total daily flow------------ .... ...___.........__gallons. 9 Septic Tank—Liquid capacity/ -__gallons Length---------------- Width---------------- Diameter.--------------- Depth................ d Disposal Trench—No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. /-------- Diameter---------�U..... Depth below inlet....Z..�.......... Total leaching area..................sq. ft. Seepage Pit No.___...._ ._. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by.......................................................................... Date........................................ 04 Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water...-_----.--___-_-_-_.-. Li. Test Pit No. 2................minutes per inch Depth of Test Pit___-------______._- Depth-to ground water........................ a O - Description of Soil..............................................................................................................................................................----•- x W U Nature of Repairs or Alterations—Answer when applicable------ __... ______�' a.d__5...............� ...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has/been�' ssuue-d b the bpgd of health. Signed ................. . ... .. ............... ......... �//��-ice / Dare Application.Approved B Application Disapproved for the following reasons: ----------------------------------------------------------------------.._...__----------------------------------- .. .. �j PermitNo. ----------./.... .... ..._..y...� -.......... Issued -----------------------------------------------------Dare------ Dace --- --------...._--,..,———— —.._-- -------.. —.. om,------.�-_,..�.�.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ge>rtiftra e of ComplittncE THIS IS TO CERTIFY, That Individual Sewage Disposal System constructed ( ) or Repaired (4C ) by - -..._.. _....-... _G �-.----------------------/� -G rS.'../Lu c.' U� Insr,J lrr �A A� _..... at .....-.... .................: .... .. � t t-t d`� �.�-- L� ..... ._ ..----------------.._... - - - f.... - - has been installed in accordance with the provisions of TITLE 5 o�The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..._.... -...-_.. ._�.�a-.... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-----__------------------�-- - 1---------------------- Inspector .....--------- -�. - - ... ----- ------------------------•---------------- ----- -� L47 06 ? THE COMMONWEALTH OF MASSACHUSETTS ✓ BOARD OF HEALTH c�s , L� 7� TOWN OF BARNSTABLE No.- ,.. FEE.•-- U— �iu�uuttl Permission is hereby granted..........----------. � .��.._..._..__.�- 1ST/�ULi to Construct ( ) or Repair (r�!q an Individual Sewage Disposal Sys 6 �� atNo. �-------------------------------------------------------------------- Street r as shown on the application for Disposal Works Construction Permit No.kr."�t'�-7h Dated------- -•-•---------------•-•-----•-- \ -------_--------------------------------- l a d of Health �j - DATE ................................. -. FORM 36508 HOBBS&WARREN.INC..PUBLISHERS J TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE A�Qjt�S7/ ,Q�C ASSESSOR'S MAP & LOT, -� INSTALLER'S NAME PHONE NO: L077:Z SEPTIC:;TANK CAPACITY /DdD 15:2 LEACHING FACiLITY:(type), a� � � (size) NO. OF.:BEDROOMS PRIVATE WELL O UBLIC WATEI j BUILDER R OWNE .QiQD�C osS DATE-PERMIT ISSUED: �O DATE."COMPLIANCE ISSUED: "7 If 72 VARIANCE GRANTED: Yes �N J G os �9h os� No.................. :S..................... THE COMMONWEALTH OF MASSACHUSETTS Ilttjj�� BOARD OF HEALTH ✓' telf ' . _I owu. - - of.-..... AR..1�1S7.AtJ. ........ ................... Applir- atiun -fur Btoposal Works Tonstrnrtion Vrrmft Application is hereby'made for a Permit to Construct ( ✓f or Repair ( ) an Individual Sewage Disposal System at: �.�T- ►- R9.E..-.l l.� --` ,QRL� - e sTA I.E------------------------ Location-Address or Lot No. .._SI_AIT_. k.......................................... .......AQIJST........ Owner Address a ......E_.rQZ.t�_...�QQ'C.geas5--------------------------- ----- Aa. ------------------------------------------- Installer Address Q Type of Building Size Lot.... *b87.....Sq. feet - U Dwelling—No. of Bedrooms_____________3........_.... _. _._._Expansion Attic ( ) Garbage Grinder ( ) .� aOther—Type of Building ............................ No, of persons._-___-6.................. Showers ( ) — Cafeteria ( ) PaOther fixtures .......... ........................................... W Design Flow-----------55___________________________gallons per pet-son per day. Total daily flow............3-W-._-.___-----_--.-.---.--.gallons. WSeptic Tank—Liquid capacitvla?Q.gallons Length----�_______- Width....a-------- Diameter---------------- Depth.--------------- x Disposal Trench—No. ................... Width.. ............. Total Length.........//-...__..-. Total leaching area...-----------------sq. ft. Seepage Pit No.._.__I-_____--____ tameter...... _..__ Depth belo inlet Seepage Total leaching area.------_-__.-__--sq. ft. Z Other Distribution box (� Dosing tank ( O tl—'I.? 7- 7 7 ~" Percolation Test Results Performed by----- drir�X __. _E! .r_�l_�......................... Date...l_4_722 7_-.�7 a - - Test Pit No. 1......2.......minutes per'inch Depth of Test Pit____________________ Depth to ground water...__._.-__.__.--..---. (q Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water_-._-.--_-___--.----.--. fY, .................•-------------------------------------------------------------------•••-••---•-•----•---•--•-••-•---•---......--•••-•-•-----•••••--------- O Description of Soil----Q---` S......L,ppxM----- ---.6.016 ��- + 4-B. ....... GP�PMJC-L V 12�_--_14 "-- 1AIMA -PN--- S�f1�?D------------------------•---------------------------....---------- W ------------------------------•---• ......... -------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable..........................______.-.-----..-.--.-.-..----.-.---------------..----------..-.-.-.-. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig ed.'_ --------- 6 _.. --•• Z-- 5----- v �Cl.1WLA .. 5 ..... . 2- •Za2`7 te Application Approved BY (�"�� Zv?il :-------------------- ------------ Date Application Disapproved for the following reasons:................................................................................................................ .......... .................................................. •••--------•-•--•-•--••-•------•••--•-•---•.......----•------••----•-••••--•-------••-•-- ------------------------------------------------- Date PermitNo......................................................... Issued-------1 --------7----- ? -------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Alipfira aan -fur Ditipwial Works Tonstrurtion Vrrufit Application is hereby'made for a Permit to Construct or Repair ( } an Individual Sewage Disposal System at: ........ ........................... ............................................. --•---............. ......... . --....................... Location-Address or Lot No. --- .......................--•.................................................................. Owner Address a ------=-�-t--- t_-- e�.-- .....................................- K. d . .t� �.✓ 1 a1 �4 . t'�t�y:L..------------------------------------------------------- Installer Address Q Type of Building Size Lot-._.`-I------- ------Sq. feet U Dwelling—No. of Bedrooms______________ _---------------------------Expansion Attic ( ) Garbage Grinder ( ) 1-1 aq Other—Type of Building ___________________________ No. of persons_____kr------------------ Showers ( ) — Cafeteria ( ) a' Other fixtures Q --------------------------------•----------------------- W Design Flow---------- 3...........................gallons per person per day. Total daily flow--------------��')-_____-__-_-_-.--......gallons. WSeptic Tank—Liquid capacitvj. .:_ ..gallons Length_'! Width................ Diameter................ Depth.._-----_..._-. x Disposal Trench—No. .................... Width-_ ------------ Total Length----- __._.__... Total leaching area--------------.-----sq. ft. Seepage Pit No_______ ___________ Diameter__.____ ___.-_ Depth belo inlet___-�2__------._•-- Total leaching area-._-.-_----_.__-sq. ft. Z Other Distribution box (✓')r Dosing tank (f} Q ' • '" '" '' `-' Percolation Test Results Performed by..___ _1,1__ a?t `��!` ............. a , ' Date 1. ,� Test Pit No. 1......f_-------minutes per inch Depth of Test Pit____________________ Depth to ground water...----._--_.--._..-__-- rX.4 Test Pit No. 2----------------minutes per inc1f., Depth of Test Pit------------ ----- Depth to ground water_..---__'_.__---_____. a, D Description of Soil----`= "= t_ ,,NF,1 c w;. kf' t t y} 'y 1 ` t�sA 4C h__ * 4_ --. (_,1 rk1 €: ---------- --------- ------------- V -----. .....................-,_�� tl1 a`---------M:-- -- --- -. .. --•--- --------- W Iti Z •.............................................F-_-__-________-____________________-___•-__•--•-------__-___--.--____--_-___-___________-_-_-----_-__-____---____-._-._-_----__-----_-__.__--________.__. UNature of Repairs or Alterations—Answer when applicable.....:............: ------------------------------------------------..........------------------- -------------------------------------------------------------'--- --------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual SSewage. Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig ed',_ . _ E' :_, '.: 1 ,. -------- ------------------------- Date i. u --------- '1 i� Application Approved By---- /" ------.A•.4.2....77 Application Disapproved for the following reasons______________________________________________________________________ ------•----------------Date -•----...... -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- IIII,, Date Permit No........................------•------------- ........... Issued...... -.`..7_- -----.......................... Date , THE COMMONWEALTH OF MASSACHUSETTS ,,.,.... �.e BOARD OF HEALTH ° .... t....�..�.4...................O.F:..._ a�uK 1 :, :►.5� ..,.-. .................................. ; �rrtt�ir��.e gf f��ut�li�tnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) � - _ Installer at .'°t-.-•-•--.- -'•--•....................................1 ` ... ...� '---------------I------. - =--- €..t..t� t has been installed in accordance with the provisions of e XI of The State Sanitary Code as described in the y__application for Disposal Works Construction Permit No ? _-_.'�'/_'7°_ _______________ dated...J4.-_ �' ............ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---------- /...` 7 a - .......................... Ins'pector................................. ................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t ........�� 3" .... ..... ....OF...... . t�i2. `... t..�.{� ... ................_........ No.............f--- FEE---—----------------- "Rripjaiittt Workii CITomitrudion Prrrutit Permission is hereby granted.......L_ti- `1'_l_ _'_� ___.__... _: '_(.-`_____________ - • to Construct G.-for Repair ( ) an Individual Sewage Disposal System at NO....� i t , }..c r t i #t' ......_I.- "\%,' � � I Street as shown on the application for Disposal Works Construction Permit _/__'� ___ Dated___ '_a-----"?7 Ay Board of Health DATE --------- --------------------------------------- �� FORM 1255 HOBBS & WAR.REN. INC.. PUBLISHERS TOWN 6F BA INSTABLE LOCATION / "/`�'Z'LLD SEWAGE VILLAGE2�A)S'?15�&'-'6- ASSESSOR'S MAP Cr LOT -®� INSTALLER'S NAME & PHONE NQ. QZQ .�(�/?/gT, �? SEPTIC TANK CAPACITY /000 Clj� /Q/J� LEACHING FACILITY:(type) � � /� (size) X /y NO. OF BEDROOMS �3 PRIVATE WELL O UBLICWA�TER�. 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