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0055 AUGUSTA NATIONAL DR - Health
Augusta National Drive Barnstable A= 355 0I5 't 1! a t f A 9 9 0 4 Legend a Parcels T - 355006 € r y` .- own Boundary #266_ ' ., ,a t x ' Railroad Tracks Buildings z k ° Painted Lines 355007 ,-,.�„ Parking Lots #73 5'r: .Y Paved s �y� 355013 unpaved #76 Driveways Paved Unpaved e$ zC Roads ..u. s &i Paved Road _01 Unpaved Road 349024 \ t ®Bridge I� t 'vf"C. �s�'' ,,,y 0 Paved Median #286 \a bm s Streams Marsh Water Bodies \Rr MW € Y S 76v f0y yL �k �G i�k$vj 3550 i'firs dp ar' . 355014 RE 349025.__ '�� ' a rGY 312 355002008- �r� � € 9kE ■ nr� t xr p #0 Y _r ttl�` $/22/2017 11"ma r ■- Map printed on: �. p is for illustration determination only.It>a not ...,.,parcel lines shown on tbis mapare onl Feet adequate for legal boundary determination ort y Vph'c Town of Barnstable GIS Unit regulatory interpretation.11tis ma does not r representations oYAseeasor's taz parcels.They are 0 42 83 O an on-the- p e,may not tree property boundaries sod do not Street,Hyannis,MA 026ot ground conditions, 6e en ren them 367 Main y generalized,may not accurate relationships to physical objects on the map Approx Scale:I iDC11= 42 feet cared cnrreot eons9tions,and nay contain cartographic errors or omi ons. such"building locstions. 508-862-4624 . ssi gis@tawn.barnstable.ma.us s 55 + .ems y S6 06, + ;G; � s O 1 o s • C ' IL 00 + s no oill + �o 61 OL5, �m s � o G� i. I� DECK cN O eP F yid S F� °�,y��-�� * oho s 0 G TOWN OF BARNSTABLE LOCATION SS Avi TrA AIA 7Dl-94— Ox SEWAGE# 2.60_ IDS VILLAGE &^0VV4 Qv/*D ASSESSOR'S MAP&PARCEL 3551 i6- INSTALLER'S NAME&PHONE NO.Alic.A/eaCAj A."—AfvNJ�R SD0 334`f7b7 SEPTIC TANK CAPACITY /0010 !:r_cr LEACHING FACILITY:(type) 4VWX1 !0/T (size) NO.OF BEDROOMS 1 Ate C,Q ax/t jb 6A 11W t. 2X%If7y OWNER AIM JD4W k4 (�. � PERMIT DATE: 23 A.1 L Zo COMPLIANCE DATE: io 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 A i 6 ® cz coV�n rw AlI< AtB1 I�'2q-3 10/0 ` No. _ Fee V v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for ;Di5po.5a1 �pgtem Con0tructiou Permit Application for a Permit to Construct( ) Repair d(J)/Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. JS A� ' 1 r"` N cT Owner's Name,Address,and Tel.No. )p 0 0 S lA tZDY 53 A u6-us1jA 1VA770ArA4- A>AdW6 Assessor's Map/Parcel 11512 O f 4-NOV "IA Qul 0 1,V4 ,509 70f 7d33 69- Installer's Name,Address,and Tel.No. �AG�OLASN. Designer's Name,Address and Tel.No. ���� ��� � �d x 277 S Y�vY,o�T �' �39 M��r� sT Y,4.G �v77J �� eT 3 1— 78 SZ4 362 9'f Type of Building: Dwelling No.of Bedrooms 1 V Lot Size sq. ft,. Garbage Grinder ( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 4115-/ Zv Number of sheets I Revision Date Title $ —j�1G ��<►/r2/S/TF /�L� 15 S�S— A064 'r ",77,daf✓.QL— Pe-/41 Cww,&9r4Qu Ili Size of_Septic Tank Type of S.A.S. LG40-1 P)T Description of Soil Nature of Repairs or Alterations(Answer when applicable) AJEAI t7—scX ¢ LB/✓E Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of • Compliance has been issued by th' 7d H th. Signed Date Application Approved by IL Date ?7 C(] Application Disapproved by: Date for.the following reasons 10, Permit No. ;L0 0 Date Issued Lf —X3`(Z) 9 3 [ Fee // C% THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i ;J 'Yes 'PUBLIIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ' ZIppgicatiou for bigo!gar *pgtem Con0truction permit Application for a Permit to Construct( ` Repair(,?Upgrade'( ) Abandon O ❑ Complete System ❑Individual Components t Location Address or Lot No. . TP J�.S �u� S i"ram hl N'r. Owner's Name,Address,and Tel.No. Je)(a rJ ;j JA�-"Dy SS U6-u S I A NAT70,v. 1— .&� /6 Assessor's Map/Parcel 015 `i/mr-7A 4ui 1,V4 _Sae 7033 Installer's Name,Address,and Tel.No. /tlleAj zoz Designer's Name,Address and Tel.No. 00'i/V 6445 �7✓Gr /?O• �3rix 2,7? ',�oT7-1 !?7t �39 /t'�sa�rJ Sr Yr�cv�uvTT� �oej- Type of Building: y Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other ~Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _ /y gpd Design flow provided �1 gpd Plan Date Lit/15' / Zo 1D Number of sheets ( Revision Date Title j=P�it G'�-,yn.�/ t AL. ,sdC C C �1�r/a c T�I �rra rr.�,,✓ter t ni �.r— /rs rN..�[t ra Size of Septic Tank Type of S.A.S. 1 C.:Ae " a)7- Description of Soil Nature of Repairs or Alterations(Answer when,applicable) A16PU D-$bX e G•!NE \ I Date last inspected: Agreement: `1 The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this-Board Health. r' Signed r" _ Date Application Approved by ` ` �"� Date - 3- Ir Application Disapproved by: 0 Date R for the following reasons r Permit No. a v D Date Issued L( "A3`f y THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (�) Upgraded ( ) Abandoned( )by at `j Jl' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No, (pot U b if dated• L1' ;2 3-f C Installer I Designer .---- •-/ /� #bedrooms Y`/ Approved design flow /t/ // gpd The issuance of this perttit shall not be construed as a guarantee that the system will function as designed. Dat i) Inspector ( �(i✓ - ,�C -� Rs _ No. aO� U m — L----- -- Fee V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migonl �§p.5tem Con5truction permit Permission is hereby granted to qonstruct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at g S and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. 0 Date t _ 7' f 0 Approved by U FROM :down cape engineering inc FAX NO. :15083629880 Apr. 28 2010 10:29AN P1 Town of Barnstable Regulatory Services 4 Thomas F. Geiler,Director Public Health vision Thomas McKean,Director 24P Main Street, Hyannis,MA 02601 Office: 509-R62-4644 1.'ax: 508-790-6304 Date: '26 AP91L Z010 Sewsio Permit# 2D10— IOR Assessor's Map/Parcel 35511 S" installer& Desi ner Certification Dorm _ Designer: DOu/N A. EA/�/jyaW//1/,� Installer: - Addrrss: Address: ?D. 8ox .277. . )U7MQ9T'7jF?ZC_fiY,d 6Z4 5- Se.Yarnscty��„ RE RA"e- On 23 A P61- 20/D /C aAS..'TAl41�_was issued a permit to-inst ] a (date) (installer) septic system at 55 AUGU-M NAT/o/✓dL Die►V'u bayed on a design drawn by (address) 'DANIEL A.WAt-Ati PC/PL.S dated 15 APRIt- 2-0 to (designer) /1' certify that the septic stem referenced above was installed substantial)P Y y according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. _ I certify that the septic system referenced above was .installed with mtkjor changes (i.e. greater than 1.W 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 to follow. Stripout(if required.) was inspected and the soils were found satisfactory. UANISLA. yn OJALA (Installer's Signature) CIVIL y N No.46502 J. In (Designer's Signature) (A' er's Stamp Here) ��6a�c +�1PtrZY - �P-- � 'j) PLEASE; RE:TWIN TO .BARNSTABLE PUBLIC HEALTH 'DIVISION CEItTIi+ICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- QUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOiJ. gAoff ct furms\designmartific:ation fnnn.doe r IKE Town of Barnstable Barnstable Regulatory Services Department . �;Ca IiARNSCAH MASS. 1639. Public Health Division.�� Q 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205009410 4/15/2010 Barbara Sternberg 55 Augusta National Drive 1,I ^ Barnstable, MA 02637 v?U l 0 I ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 1 The septic system located at 55 Augusta National, Barnstable MA was last inspected on March 17, 2010,by Mark Polselli, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component.due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PE ER OF THE B ARD OF HEALTH omas cKean, R.S., CHO O Agent of the Board of Health c� 0 i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. �U N Gi�IOH� L ✓ Property Address / Owner Owner's Name n information is / ,, �QH� /"Z 00 63/ required for y" every page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your ✓ff 0/S�i�� ~ cursor-do not Name of Inspector use the return key. Company Name P�O O Company AddresX--a— s-fka ICI City/Town State Zip Code Telephone Number License Number —o B. Certification a ' I certify that I have personally inspected the sewage disposal system at this address and that then information reported below is true, accurate and complete as of the time of the Inspectionk5he Inspection was performed based on my training and experience in the proper function and maintenance of 0!j site sewage disposal systems. I am a DEP approved system inspector pursuant do Section 15.39of Title 5(310 CMR 15.000). The system:' csa . ❑ Passes ❑ Conditionally Passes Fails v ❑ Needs Further Evaluation by the Local Approving Authority wal�vv 3 Inspect f s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10:000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-09/08 Title 5 Official Inspect on Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name/' �' ) information is / U V`7✓h A, a N t 14 Od 6,7i required for C/ State Zip Code Date of Inspection every page. City/Town 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-09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntaryy Assessments r( L5J U HST ti �A /Oa I !/✓ Property Address PIPT, Owner Owner's Name information is / /� I� required for C��✓�I'�►ti dHr + i �a� ✓ �� every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rs Property Address rh Owner Owner's Name/� n I� information is / M�4 Q 6,41 O �� / required for C/ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 ❑ Lam" 4 P than 1/z day flow t51ns•09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form on My Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 r S��- / / 4 yS1 A /r6+ /Q�aL ✓ Property Address / - Owner Owner's Name information is U i/��a atoll1.� required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 2 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑vim Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Q/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 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.] ❑ Q/ 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 406 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address S-e,�� der Owner Owner's Name information is C�VVI v►-jr, 0. required for every page. cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No �❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ ❑/� Have large volumes of water been introduced to the system recently or as part of this inspection? �❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) [.�❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? Ql"� ❑ Were all system components, excluding the SAS, located on site? [j""' ❑ 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: ❑ [j0'0"- Existing information. For example, a plan at the Board of Health. a ❑ 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): l5ins-09/06 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 rr ' Property Address / / ,_Vero_be - Owner Owners Name /n information is (,4 ✓l'jd.fM a"I d required for / every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes 3-9o— Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes ® �o Seasonal use? ❑ Yes 51—Pdtr Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes [�-�o Last date of occupancy: Cu rre~, 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: 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage ispo4al System Form -Not for Voluntary Assessments Property Address Owner Owner's Name �J /� n /,, information is G.��p F1 4 0 ,i3 X 1/`�V required for (CCy/// [� 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 Syste Type tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ In 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments 4 Property Address Owner Owner's Name /� information is required for l!/ Y41P41 r,, 6LN i State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Approximate age of all compone s, date installed (if known) and source of information: L� j n,•C C___ Were sewage odors detected when arriving at the site? ❑ Yes a No Building Sewer(locate on site plan): Depth below grade: feet �C �iaonstruction: cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material construction: oncrete ❑ 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: s y Sludge depth: - t5ins•09/08 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 SS Property Address Owner Owner's Name information is C�{„��a Q�(,�' required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): O 152(, �lQ ✓��-���� 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-09/08 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 Property Address Owner Owner's Name information is 64 f41Mg emu, Qo263� -3—O 0 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N Property Address rrt � Owner Owner's Name,� information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert a Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M SrU f✓1S �� /VF�lO GL �'i Property Address I- Owner Owner's Name d � A information is required for State 2i Code Date of Inspection every page. City/Town p � D. System Information (cont.) Type. leaching pits number: ❑ 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.): H f<tsl o d—. C71 4Z4 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System // Form -Not for Voluntary Assessments Y Property Address Owner owner's Name/1 information is / � ��.j� QN roar>3� 3- e ery paed ge. City/Town C/ G State Zip Code Date of Inspection every P 9 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.): 15ins•OW08 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 Property Address Owner Owner's Name information is C �' required for N��� every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate r water supply enters the building. Check one of the boxes below: tch in the area below attached separately 15ins+09/09 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address —lam, ! vo Owner Owner's Name information is required for Da 632 U��� every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 10 C; Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: 144 ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 4'— C) lit k' G Ll Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 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 v Property Address Owner Owner's Name A information is required for C� ✓ �/7" �_ r7—///n� -1a ��A �r every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist E?ell'nspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed C11"S'ystem Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file L t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 to Page 10 of I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C ,T _ SYSTEM INFORMATION (contmued) -'PFoperty-Address: 55 Augusta National Dr. -` _Cummaquid,Barnstable_ zee Owner's Name: F. W. McAbee_ Date of Inspection:_6127/05_ 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 wafer supply enters the building. � p C /O J)IZ(V11,W yjA C = 236 b e - 21 ew t N i ,� ./ / � N ��l COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION e Map:-366— Lot:_149 Par._15 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_55 Augusta National Dr. �,j"� ej/-5 _Cummaquid,Barnstable_ Owner's Name: F.W.McAbee_ Owner's Address: _same Date of Inspection:_6%27/05_ ,J Name of Inspector: Dion C.Dugan Company Name:— 1543 Main St. Mailing Address: Brewster,MA 02631 Telephone Number: 508-896-9390 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 DEF approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ` X Passes Conditionally Passes ° w 1�7. Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 6/27/05_ : 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: *Recommend: Maintenance pumping 3—5 yrs. ***May have running toilet.Running toilets can cause early leach pit failure. ***Recommend Septic Tank be pumped now. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_55 Augusta National Dr. _Cummaquid,Barnstable_ Owner's Name: F.W.McAbee_ Date of Inspection_:_6/27/05 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: _N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Augusta National Dr. _Cummaquid,Barnstable_ Owner's Name:_F.W.McAbee_ Date of Inspection:_6/27/05 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(l)(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 are triggered.A copy of the analysis must be attached to this form. 3. Other: r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_55 Augusta National Dr. Cummaquid,Barnstable_ Owner's Name: F.W.McAbee_ Date of Inspection: 6/27/05 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_ 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 YZ 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 1 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 form.] 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:N/A To be considered a large system the system must.serve a facility with a design flow of 10,000 gpd to 15,000 1Td- 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 _N/A_ the system is within 400 feet of a surface drinking water supply _N/A_ the system is within 200 feet of a tributary to a surface drinking water supply —N/A_ 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 Page 5 of I I 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. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_55 Augusta National Dr. _Cummaquid,Barnstable_ Owner's Name: F.W.McAbee_ Date of Inspection:_6/27/05 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: 55 Augusta National Dr. _Cummaquid,Barnstable_ Owner's Name:_F.W.McAbee_ Date of Inspection:_6/27/05 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: 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):_no Seasonal use:(yes or no):_yes_ Water meter readings,if available(last 2 years usage(gpd)): 2003:_161,000 gal. 1 2004: 192,000 gal. Sump pump(yes or no):_no_ (w/sprinkler system) Last date of occupancy:_March 2005 COMMERCIAL/INDUSTRIAL: N/A Type of establishment: N/A Design flow(based on 310 CMR 15.203): avd Basis of design flow(seats/persons/sq t,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumping: unknown owner 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 NO_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: _Installed_not on record B.O.H. Were sewage odors detected when arriving at the site(yes or no):NO_ Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Augusta National Dr. _Cummaquid,Barnstable_ Owner's Name:_F.W.McAbee_ Date of Inspection: 6/27/05 BUILDING SEWER(locate on site plan) Depth below grade: 32"_ Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_N/A Comments(on condition of joints,venting,evidence of leakage,etc.): Joints are tight,venting is through the roof,no signs of leakage. SEPTIC TANK: YES locate on site plan) Depth below grade: 20"_outlet cover built up to grade w/cast iron cover 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: 1000 Gallon_ Sludge depth:_16" Distance from top of sludge to bottom of outlet tee or baffle:_14"_ Scum thickness:_2" 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:_by tape and rod Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Recommend septic tank be pumped now.Tank and tees in good condition,no sign of leakage. *Recommend:Maintenance pumping every 3—5 yrs. GREASE TRAP: N/A 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:_55 Augusta National Dr. _Cummaquid,Barnstable_ Owner's Name:_F.W.McAbee_ Date of Inspection:_6/27/05 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: YES (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0"_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box is level with some signs of carry over and no signs of leakage w/C.I.cover built up to grade. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_55 Augusta National Dr. —Cummaquid,Barnstable_ Owner's Name: F.W.McAbee_ Date of Inspection:_6t27/05 SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number:_one 6'x 6'pit w/1'stone_ 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 found w/37"of liquid in it,no staining,no sign of failure. CESSPOOLS:N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): *Recommend: Maintenance pumping every 3—5 yrs. PRIVY: N/A(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): • Page 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Augusta National Dr. _Cummaquid,Barnstable_ Owner's Name:_F. W. McAbee_ Date of Inspection:_6/27/05_ 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. E C /0 cJ�W 4Y A - C = 3G � b - C = 236 /7 21 w ,C D� Page 11 of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_55 Augusta National Dr. _Cummaquid,Barnstable_ Owner's Name:_F.W.McAbee_ Date of Inspection: 6/27/05 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_22_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: You must describe how you established the high ground water elevation: By U.S.G.S.Atlas HA—692. >5'of separation. I �PfP s A � Sond i o a x 54.85 Dennh h hh/ Pond x 56.27 0 h6 Locus 3 x 55.17 SERVICABLE LEACH PIT FOUND DURING TEST HOLE PROCEDURE 5I xit 7 5$ 12" OAK 9 Route (' CRUSHED PIPE FROM D'BOX TO BE REPLACED WITH SCH. Yarmouth x 75 60.95 40 4" PVC PIPE. PROVIDE MIN. 1% PITCH TO LEACH PIT. Campground 9. 6 NS tI% / x 55.25 12" 0 K ■ cow i DEAD PI E 8 EXIST. LEACH PIT AS PER DEP INSPECTION LOCUS MAP I rn REPORT DATED 6/27/05. INSTALLER TO 1 x , w CHECK CONDITION OF THIS PIT DURING NOT TO SCALE \ / INSTALLATION OF NEW D'BOX & LINE; x 64.08 RE-CONNECT IF IN SUITABLE CONDITION, 62.1 OTHERWISE PUMP AND FILL WITH CLEAN ASSESSORS MAP 355 PARCEL 15 x x 54.18 co , SAND. x 5 .63 \- 197 0) I x 58.20 x 56.12 14" OAK 61.7 (0 61.91 REPLACE EXIST. D'BOX WITH NEW H-10 Cn rn I x 6d.51 8 D'BOX °D `n x 59.59 6�87 x 0 NOTES � / 3.43 x 57.70 x 59.6 61. 2 CAN 1. DATUM IS APPROX. NGVD 62.63 BRICK / 2. MUNICIPAL WATER IS EXISTING PATIO BENCH MARK - ON G� / 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. CORN. OF DECK EL = 64.1 p� �.�2 / 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS TO BE AASHO H-1Q EXIST. DWELl1NG, / 5. PIPE JOINTS TO BE MADE WATERTIGHT. 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH 310 CMR 15.000 (TITLE 5.) LOT 149 7. / 36,905 t SF NOT TO O PROPOSED N TO BE USEDIS PLAN IS R LOT LINE STAKING ANY OTHER PURPOSE. 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD J OF HEALTH. / 4,9 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION OF ALL UNDERGROUND & c, / / v OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF �y// �P//// / Q► WORK. J R,Sa SITE PLAN q=S9 43 OF / LSH OF MA \ OF Ass �� DANIELs9`y 55 AUGUSTA NATIONAL DRIVE NIELA.9 o A. N CUMMA UID N off 508-362-4541 ALA 0 40 Q0 fax 508-362-9880 CI L cn I downcape.com © -o OF ` arm PREPARED FOR ANIE L down cope engineering, Inc. ��" � �• � �� .� D A cy� MGM JOHN SHEEDY civil engineers OCIVILJ A. land surveyors ' q No.46502 No.40980„ APRIL 15, 2010 939 Main Street ( Rte 6A) �� �`� � °P,�sS 0 YARMOUTHPORT MA 02675 ass ONA` qN°SUR I Scale: 1"= 20' 0 10 20 30 40 50 FEET 10-066 DANIEL A. OJALA, PE, PLS DATE