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HomeMy WebLinkAbout0345 BONE HILL ROAD - Health 345 Bone Hill Road. A [re 1 r .. � :-=a:=..�.-.,�.., ��.- ---`.- .r_._:. _�-s� -=•,� _. ,�_.. _ ,. ems...-.:: _ -_co--r a:= =--..a= �-��... _� - -- - _ � - �.._-.v - - ---__ _. _. � --��.,_._--_� a_ .��_ a __�_.. e.r-_ _ _- r C I ' 33 .Commonwealth of Massachusetts p Title, 5 Official Inspection Form Subsurface SewageDisposal System Form - Not for Voluntary Assessments c � 345 Bone Hill Rd. System 1 F ' Property Address Mass Audubon Long Pasture Owner Owner's Name ` information is required for every Cummaquid Ma. 02637 1.1-14-20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. important:When A. Inspector Information filling out forms on the computer, Michael Sears use only the tab key to move your Name of Inspector cursor-do not Jim The Inspector Man Use the return Company Name key. P.O.Box 784 raa Company Address ` West Yarmouth Ma. 02673 City/Town State Zip Code 508-364-439.8 S114430 Telephone Number License Number B. Certification I certify that: I am.a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Z 'Passes �anuwnruuu, 2. ❑ Conditionally Passes z� c� MICHAEL '.to SEARS 3. ❑ Needs Further Evaluation by the Local Approving Authority -'0. _ *% No.SI14430 :c_ 4. ❑ Fails �r.FRTIF�• i���i;F•$ I 111111111\'<���`` -14-20 Inspector's Signatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection_ If the system has a design flow of ` 10,000 gpd or greater, the inspector and the system owner shall submit the,report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. '- Please note: This report only describes conditions at the time of inspection and under the f conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts �w Title 5 Official Inspection Form �I Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments u 345 Bone Hill Rd System 1 Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaguid = Ma. 02637 11-14-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that,any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. ` Comments: 2 Cesspools ` 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not>determined" (Y;N, ND),for the following statements. If"not. determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System-will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating.that the tank is less than 20 years.old is available.' ❑ Y ❑ N 0 ND'(Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 r c Commonwealth of Massachusetts �v Title 5 Official Inspection Forrn i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 Bone Hill Rd.' System 1 Property Address. Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaquid Ma. 02637 11-14-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary.(cont.) j 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a,broken, settled or uneven distribution box. System will pass inspection if(with approval,of Board of Health): ❑ broken pipe(s) are.replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): T1 distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 'obstruction is removed ❑ Y" ❑ ,N ❑ ND (Explain below):. 3) Further Evaluationis Required bythe Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a.. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect,public health, safety and the.environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 F Commonwealth of Massachusetts �n Title 5 Official Inspection` Form ' i, Subsurface Sewage Disposal System.Form Not for Voluntary Assessments 345 Bone Hill Rd. System 1 Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaguid ' Ma. 02637 11-14-20 page. City/Town State Zip Code Date.of Inspection C. Inspection.Summary (cont.),' El Cesspool or privy is within 50 feet of a.surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning ima manner that protects the public health, safety and environment:' ❑ The system has aseptic 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. c. Other: 4 System, Failure Criteria Applicable to All Systems: You must indicate"Yes" or;"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component.due to overloaded or clogged SAS or cesspool ❑ " Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesslpool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 4 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection, Form �I Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments <,V � 345 Bone Hill Rd. System 1'' Property Address Mass-Audubon Long Pasture Owner Owner's Name information is required for every Cummaquid Ma: - 02637 11-14-20 page. City/Town a State Zip Code Date of Inspection. C. Inspection Summary (cont.) ; 4) • System Failure Criteria Applicable to All Systems:(cont.) Yes No Static liquid level'in the distribution box above outlet invert,dueto an-overloaded ❑ ® or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow, El 1z Required.pumping more.than 4 times in the last year NOT due to clogged or obstructed_P ip e(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below.high ground water elevation. El ® 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 water supply well. [I ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. 0- • ® 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 2000 gpd- 10,000 gpd The system fails. I have determined that one or more of.the above failure El z criteria exist as described in 310.CMR 15.303, therefore the,system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5 Large Systems: To be considered a large system the system must serve a facility with a 9 Y g Y Y _ Y 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 C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 Bone Hill Rd. System 1 Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaquid Ma. 02637 11-14-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes' to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® 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? ❑ 2 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? ® El available 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? ® El Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the.baffles or tees, material of construction, dimensions, depth of liquid; depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® 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)] / i - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for'Voluntary Assessments « 345 Bone Hill Rd System 1 Property Address Mass Audubon Long Pasture Owner Owner's Name information is Ma. 02637 11-14-20 required for every Cummaquid page. Cityrrown State Zip Code Date of Inspection D. System Information 1.. Residential Flow Conditions: Number of bedrooms (design): 1 Number of bedrooms (actual): 1 DESIGN flow.based,on 310.CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 Description: Y NA Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment`unit? _ ❑ Yes ® No If yes, discharges to:- 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 NA Water meter readings, if available (last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No NA Last date of occupancy: Date M t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts , �v Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments u- 345 Bone Hill Rd` System 1 Property Address Mass Audubon Long Pasture " Owner Owner's Name information is required for Cummaquid Ma: 02637 11-14-20 every page. CityTTown State Zip Code. Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR.15.203): Gallons per day(gpd) i . Basis of design flow(seats/persons/sq.ft., etc.):.. Grease trap present? ❑ Yes ❑ No Water treatment,unit present? ❑ Yes ❑ No ` If yes, discharges to: � -Yes N o Industrial waste holdin tank resent. ❑ 9 p , Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: bate Other(describe below): 3. Pumping Records: p 9 r Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® ~No If yes, volume pumped:, gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Bone Hill Rd. System 1 u� Property Address Mass Audubon Long Pasture 4 Owner Owner's Name information is required for every Cummaguid Ma. 02637 11-14-20 page. City/Town State Zip Code Date.of Inspection D. System Information 4. 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 tech nology.fAttach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system_operator under contract . ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)-and source of information: NA Were sewage odors detected`when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 20„ Depth below grade: feet Material of"construction: ❑ cast iron ®40.PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 a • Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345-Bone Hill Rd., System 1 u� Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaquid Ma. 02637 11-14-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. 'Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years j Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle- Scum thickness Distance from top of scum to top of_outlet tee or baffle Distance from bottom of scum.to bottom of outlet tee or baffle How were dimensions determined?' Comments (on pumping recommendations, inlet and outlet tee or baffle condition,;structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .II? Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, !% 345 Bone Hill Rd System 1 u— Property Address Mass Audubon Long Pasture Owner Owner's Name information is Ma. 02637 11-14-20 required for every Cummaquld : page. City/Town State Zip Code Date of Inspection D. System Information (cont:) 7. Grease Trap (locate on site plan):, Depth below grade: feet Material of construction: El fiberglasspolyethylene ❑ other ex lain): concrete metal �❑ _❑ (explain): ❑ 9 A , Dimensions: F Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping; Date Comments (on pumping recommendations, inlet and outlet tee of baffle'condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be,pumped•at time of inspection)(locate on site plan): Depth below grader Material of construction; ❑ concrete ❑ metal ❑fiberglass -❑ polyethylene ❑ other(explain): Dimensions: M Capacity: gallons Design Flow: gallons per day j t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form +_ �I Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 345 Bone Hill Rd. System 1 Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaquid Ma. 02637 11-14-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): 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.): I i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Bone Hill Rd System 1 u— Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaquid Ma. 02637 11.-14-20 page. Citylfown State Zip Code Date of Inspection D. System Information (cont) 10. Pump Chamber(locate on site.plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order:' .❑ Yes ❑ No* Comments (note condition of pump chamber, condition of,pumps and appurtenances, etc.): 1. * If,pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers,:. number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form I. �1% Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 Bone Hill.Rd. SY stem 1 Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaquid: Ma. 02637 11-14-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont:) Comments (note condition.ofsoil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r SAS is a over flow cesspool pool is clean and dry with no sign of failure 12. Cesspools,(cesspool must be pumped as part of inspection) (locate on site plan): - 2 Number and configuration 1 611 Depth —top of liquid to inlet invert Depth of solids layer _ 0 0 Depth of scum layer 6'x6' Dimensions of cesspool Block Materials.of construction Indication of groundwater inflow ❑ Yes ® No Comments (note condition-of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool has 3' of water and is in working order t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of.18 - r Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System:Form -Not for Voluntary Assessments 345 Bone Hill Rd. System 1 Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaguid Ma. 02637 11-14-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 1 13. 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.): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c � Commonwealth of Massachusetts Title 5{Official Inspection Form I Subsurface Sewage.Disposal System Form -Not for Vol untary.Assessments . � 345 Bone Hill Rd. System 1 Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaguid Ma. 02637 . 11-14-20 page. City/Town State Zip Code Date of Inspection D. System Information .(cont.) 14. Sketch Of Sewage Disposal System: Provide'a view of the sewage disposal system, including ties-to at least two permanent reference landmarks.or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below_ ❑. drawing attached separately .01 0-0 � - 6 .;.5 3_ M1 �auumnuu��� H OF 5_ MICHAEL yN= o. SEARS I rn _ 10 0 No.SI14430 !Z;' F n is n ►����`\` t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts-. Title 5 Official inspection Form i1a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments n �. 345 Bone Hill Rd. System 1 u Property Address Mass Audubon Long Pasture Owner Owner's Name information is required for every Cummaguid Ma. 02637_ 11-14-20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20' 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 lf,checked, date of design plan reviewed: Date Z� Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database.-explain: You must describe how you established the high ground water elevation: SAS is more then 20' over visible water t Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form _ II Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1, �� T! i 345 Bone Hill Rd. System 1 _ V t Property Address Mass Audubon Long Pasture' Owner Owner's Name , information is Cumma Uld required for every, a Ma. 02637 11-14-20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist t Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this„section. F. ® B: Certification: Signed& Dated and 1, 2; 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16'or attached For 15: Explanation of estimated depth to high groundwater included Cr,le Nd I nC,l-ittilr �h �.ay,s y�.��• f t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 L poi Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Bone Hill Rd. System 2 _ Property Address Mass Audubon Long Pasture Owner Owner's Name ' information is Cumma uid Ma. 02637 11-14-20 ` required for every — -g -� page. City/Town State Zip Code Date of Inspection , }Y� t Inspection results must be submitted on this form. Inspection forms may not be altered'in,any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, Michael Sears use only the tab _ ---- -- --- — - -- key to move your Name of Inspector cursor-do not Jim The Inspector Man use the return Company Name key. P.O.Box 784 — raa Company Address West Yarmouth Ma. _ 02673 City/Town State Zip Code 508-364-4398 S114430 Telephone Number License Number B. Certification I certify that' I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes ```Atu►Wnttpgii jN OF Mgss 2. ❑ Conditionally Passes cy MICHAEL .Ln% 3. ❑ Needs Further Evaluation by the Local Approving Authority : ICI. SEARS *. No,SI14430 r co Z 4. ❑ Fails ..A'r'cFRTIF��� mN 11-14-20 Inspector's Si ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health,or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system'owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 l " of Commonwealth of Massachusetts qg Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 Bone Hill Rd. System 2 _ - Property Address Mass Audubon Long Pasture Owner Owner's Name information is Cummaquid' Ma. 02637 _ 11-14-20 required for every State Zip Code Date of Inspection page City/Town C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303'or in 310 CMR 15.304 exist. Any failure criteria not evaluated are . indicated below. Comments: 1000 gal tank, pit _ 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes","no" or"not determined",(Y, N, ND)for the_following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal.septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 L ° Commonwealth of Massachusetts Title 5 Official Inspection form 111. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Bone Hill Rd. System 2 Property Address Mass Audubon Long Pasture Owner Owner's Name information is Ma. 02637 11-14-20 required for every Cummaquid — page. City/Town M State Zip Code . Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired: ❑ Observation of sewage backup'or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with`approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑` N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled'or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health):, ❑ broken pipe(s) are replaced ❑ Y ❑. N ❑ ND (Explain below): ❑ obstruction is removed. ❑ Y ❑ .N ❑` ND (Explain below): 3) Further Evaluation is Required by the.Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. . a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 q Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 f commonwealth of Massachusetts Title 5 Official, Inspection Form <i Subsurface Sewage Disposal System Forme-Not for Voluntary Assessments 345 Bone Hill Rd.' System 2 t - _- u Property Address Mass Audubon Lon asture - Owner Owner's Name -, information is M 02637 11-14-20 required for every Cummaquid a.---- a. -- —_ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.)_ ❑ Cesspool or privy is within 50 feet.of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment:, ❑ The system has a septic tank and soil absorption system (SAS) and.the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. , ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well; 0 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. c. 'Other:. 4) System Failure Criteria Applicable to All Systems: You must indicate".Yes" or"No"to-each of the following for all inspections: Yes No i ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ Hill Rd. System 2 _ --- 345 Bone Property Address P Y Mass Audubon_ Long Pasture Owner Owner's Name information is Cummaquid Ma. 02637 11-14-20 required for every - page. City/Town State Zip Code Date of Inspection C. Inspection Sumlmary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No M Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ®. or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6 below invert or available volume is less than '/z day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ c ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary-to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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 2000 gpd - 10,000 gpd. ❑ ® The system fails.I.have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails..The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section C.4. Yes No, ❑ ❑ _ the system is within 400 feet of a surface drinking water supply l ❑ ❑ - the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 7t4 Commonwealth of Massachusetts _ �� _ , Title .5 Official InSpection Form 111� _ i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 345 Bone Hill Rd. System 2 Property Address Mass Audubon,Long Pasture Owner Owner's Name information is Cummaquid. Ma. "` 02637'. 11-14-20 required for every - -- ---- page. City/Town - State Zip Code Date oflnspection C. Inspection Summary-(eont.) If you have answered."yes" to any question insSection C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed .under Section C.4 shall upgrade the.system in accordance with 31.0 CM 15.304. The system owner should contact the appropriate regional office of the Department: 6. You must indicaIte"yes"or"no"for each of the following for all inspections: .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? ® 0 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 fo-r 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: f ❑ ® 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)1 l - t5insp.doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 cC\ Commonwealth of Massachusetts Title 5 Official Inspection - Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 345 Bone Hill Rd. System Property Address Mass Audubon Long Pasture Owner Owner's Name J information is Cumma uid Ma. 0263.7 11-14-20 . required for every —�--- -- - page. City/Town State , Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 1 -— Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 Description: NA Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: - - - Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? Z Yes ❑ No NA Water meter readings, if available (last 2 years usage (gpd)): ----- Detail Sump pump? ❑ Yes ® No NA .Last date of occupancy: Date t5insp.doc-rev:7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official. Inspection Form I s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 345 Bone Hill Rd. System 2 Property Address Mass Audubon Long Pasture Owner Owner's Name information is Cummaquid Ma. 02637 11-14-20 required for every -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Canons per day(gpd) . Basis of design flow(seats/persons/sq.ft,, etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: — = Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readingsj if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? - Reason for pumping: _---- -- t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 345 Bone Hill Rd. System 2 Property Address Mass Audubon_Long Pasture — --- —. -- Owner Owner's Name information is Cumma uid Ma. 02637 11-14-20.: — required for every CitylTown State Zip Code Date of Inspection page. D. System Information (cont.) 4. Type of System: Septic tank,'distribution box, soil absorption system ❑ Single cesspool " ❑ Overflow cesspool ❑ Privy El Shared system (yes or no) (if yes;attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach.a copy of the DEP approval. ❑ Other(describe); Approximate age of all components, date installed (if known)and source of information: F . NA -- Were sewage odors detected when arriving at the site? 0 Yes. ® No 5. Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain):_ Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 t5insp.doc-rev.712612018 Commonwealth of Massachusetts Title 5 official Inspection Form W Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 345 Bone Hill Rd. System 2 Property Address Mass Audubon Long Pasture — Owner owner's Name information is Cumma uid Ma.'. 02637 _ 11-14-20 required for every -----� — State Zip Code Date of Inspection page. CityfTown D. System Information (cont.) 6. Septic Tank(locate on site plan): 12" Depth below grade: feet Material of construction: concrete metal ❑fiber9 lass ❑ polyethylene ❑ other(explain) . ❑ 1000 gal .. If tank is-metal, list age: .; years Is age confirmed by'a Certificate of Compliance? (attach a copy of certificate) ❑' Yes ❑ No 1000 awl Dimensions-- Sludge depth: 11 Distance from top of sludge to bottom of outlet tee or baffle 29 0 Scum thickness _ 811 - Distance from top of scum to,top of outlet tee or baffle — Distance from bottom of scum to bottom of outlettee or baffle Sludge judge, tape 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.): 1000 gal tank with in:and out baffles in place; inlet,cover at grade, outlet cover 12" below grade t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form i� Subsurface Sewage Disposal.System Form Not for Voluntary Assessments 345 Bone Hill Rd._S ststem 2_ — Property Address Mass Audubon Long Pasture Owner Owner's Name information is Cummaquid_ Ma. 02637" 11-14-20 required for every City/Town State Zip Code,-., Date of Inspection. . page. D. System Information (cont.)' (locate on site plan): 7. Grease Trap i p , . , Depth below grade: feet Material of construction. ❑ concrete y "❑ metal. ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: — Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): , 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grader Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 16 t5insp:doc rev.712612018 Commonwealth of Massachusetts • Form 1v Tale 5 Official :lnspec' Fo Subsurface Sewage Disposal System Form-Not for.VoLuntary Assessments 345 Bone Hilt Rd. System 2 -- -- Property Address Mass Audubon Long Pasture —--. --- Owner Owner's Name 7 information is Cummaguid _,._ Ma. - 02637 11-14-20 required for every — - State Zip Code Date of Inspection' page Cityrrown D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes El No Alarm level —_-- Alarm in working ❑ Yes ❑ No Date of last pumping: Date -- Comments (condition'of alarm and float switches, etc;): T *.Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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 distributiomto outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Title 5 Official Inspec t5insp.doc rev.7/26/2018tion Form:Subsurface Sewage Disposal system Page 12 of 18 - Commonwealth of Massachusetts Title 5 Official Inspection Form nts Subsurface Sewage Disposal System form =Not for Voluntary ASS2SSme 345 Bone Hill Rd. System-2 — _�� / Property Address _Mass Audubon Long Pasture - --- —-— Owner Owner's Name Ma 02637 11-14-20 information is Cummaquid _ — - required for every — State Zip Code Date of Inspection page city/Town D. System Information (cont.) 10. Pump Chamber(locate on site plan): ❑ Yes ❑ No* Pumps in working order: ❑ Yes. ❑ No*. Alarms in working order: 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 1 ® 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: — Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts �vr Title 5 Official lnspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 Bone Hill Rd. System 2 " — --- -- �� Property Address Mass Audubon Lono�c Pasture______ - -- Owner Owner's Name information is Cummaguid Ma_ 02637 _ 11-14-20 required for every State Zip Code Date of Inspection page Cityfrown . D. System Information (cont.) " 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is a 1000 gal pit, pit is clean and dry with no sign of failure 12. 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 a ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): } I ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System t5insp.doc-rev.7/26/2018 Page 14 of 18 1�tll� Commonwealth of Massachusetts Title 5 official Inspection Form subsurface Sewage Disposal System Form Not for Voluntary Assessments 345 Bone Hill-Rd. System 2 r Property Address; Mass Audubon Long Pasture — Owner Owner's Name information is Ma. 02637 11-14-20 required for every Cummaquid__ -- State Zip Code Date of Inspection page City/Town D.-System Information (cont.) 13. 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.): s} Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of-Massachusetts r Title 5 Official., Inspection Form _Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 Bone Hill �. _ — Property Address Mass Audubon Lon Pasture Owner Owner's Name information is _Ma.;_ _02637 . 11-14-20 .._ Cumma uid required for every --- — State Zip Code Date of Inspection page City/Town D. System Information (cont.) 14. Sketch of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �-a • S,,a Yr�� 0 5 OF qq ```,aunty urniq MICH .ti. � ct''/ . SEARS *. No.SI14430 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 t5insp.doc•rev,712612018 i Commonwealth of+Massachusetts v Title 5 Official Inspection Form li Subsurface Sewage Disposal System Form-_Not for Voluntary.Assessments 345 Bone Hill Rd. System 2 — `J Property Address Mass Audubon Lona Pasture.:. Owner Owner's Name information is ` Cumma uiq d __ _Ma• 02637 11-14-20 —. required for every City/Town State Zip Code Date.of inspection page. D. System information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20' - 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: pate. - ® Observed site (abutting:propertylobser*vation hole within 150 feet of.SAS) ❑ Checked with local-Board of Health -explain: ❑ Checked=with local excavators, installers=(attach documentation) ❑ Accessed'USGS database explain: _ You must describe how you established the high ground water elevation: SAS is more then 20' over visible water _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official InspectionfForm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 345 Bone HiII Rd. S sy tem2' _--- ---.. — --- I `r Property Address P Y Mass Audubon Long Pasture - - Owner Owner's Name information is Cmm�uid Ma. 02637 11-14-20 u - required for every State Zip Code Date of Inspection page City/Town E. Report Completeness-Checklist Complete all applicable sections of this form inclusive of:, ® A. Inspector Information: Complete all fields in this section.. ® B. Certification: Signed& Dated and 1;2, 3, or 4 checked ® C. Inspection Summary: 1, 2,3, or 5 completed as appropriate. .' f 4 (Failure Criteria)..and 6 (Checklist)completed ® D. System Information: For 8; Tight/Holding Tank-Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on'pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 14 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 t5insp.doc rev.712612018 SITE PLAN REVIEW STAFF MEETING Scheduled for 2:00—3:30 May 28,2019 Planning& Development Department 200 Main Street,Hyannis,MA NEW SITE PLAN REVIEW APPLICATIONS: SPR 036-19 Mass Audubon Long Pasture Preliminary 345 Bone Hill Road, Cummaquid Informal : Map 337 Parcel 010-001 & 005; Map 336-101 Zoning: RF-1 Proposal:: New one-story 1,420 s.f. visitor's center called the "Discovery Center" to include a reception/exhibit area and 2 program rooms. 2 ADA bathrooms and 2 small storage rooms are proposed. New grading proposed for ADA entry pathway. CONTINUED/REVISED SITE PLAN REVIEW APPLICATIONS: SPR 082-18 Pain D'Avignon 15 Hinckley Road, Hyannis Map 311, Parcel 020 Zoning: B, GP Overlay Revised Proposal:: Pain D'Avignon is proposing to contruct a small addition (663+/- s.f.) onto the existing building leaving the patio area unchanged instead of enclosing it. This additional floor space would be utilized as a multi-function room with large screen television and fireplace, and will include a new entry area with hostess station. The addition and improvements will enable Pain D'Avignon to increase seating capacity from 82 to 133 and provide customers with a higher quality experience. A 2,000 gallon grease trap was recently installed to accommodate the increase in seats to 133. Parking requirements will also increase from 37 to 54 spaces. The revised proposal provides a total of 68 parking spaces. E 1 . AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION SEWAGE n-V-! cTiv,� VILLAGE ASSESSOR'S MAP&LOT —Q;o fa INSTALLER'S NAME&PHONE NO. SyCc SEPTIC TANK CAPACITY 4000001 LEACHING FACILITY:(type) t'CS3Paa� f— /nZ (size) NO.OF BEDROOMS ,fin ` /� BUILDER OR OWNER /�f- 54c en,4^ -F4, ea PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: b / Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7•Ld 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 ftci)ity) / Feet Furnished by—AL1 /I&CAH ..�E�"'d• �0 3 0 T ' t� 3 �7 130 � ta� CessPo� 1 1 I Y http://issgl2/intranet/propdata/prebuilt.aspx?mappar=337010001&seq=1 3/13/20191, Town o arnstable APPLIC OR SITE PLAN REVIEW *INFORMAL* Ellen Swiniarski,Coordinator (508)862-4679 APPLICANT Name: I-ViSlI 4i �Ct2�S-Thnl Address: WL L/Qj KV-(,ic•n-c,rS **Official Use Only*" 15 ®cl-f Or t..n Telephone: S4 t, EMAIL: k.nAizeSian (?�nar�.I,.;k2LkS.tGM LOCATION Business Name: IIRA-SS "\)1 0,1 btJ" ekiTLqv, Assessor's Map# _Parcel# I-S 3, Property Address: 3D,v6- *tt,tr - _ GUAAMIi,4ob. A4A- nmo3 ZONING DISTRICT CLASSIFICATION *".MUST BE COMPLETED** District 2F-1 Overlay(s) AV Lot Area Lo Sq.Ft. IL Ac. Setbacks(ft.) Front_36 Side 1` Rear 1S PARKING SPACES On-Site Off-Site HP: GROUND WATER PROTECTION OVERLAY DISTRICT REQUIREMENTS: DISTRICT: Lot Coverage (%) Required Proposed Site Clearing (%) Required Proposed Please provide a brief narrative description of your proposed project: nf1C,-V V\S VQA!S Gam, t2 . GAcLL+�D 'ttt>i. '' DIScavC-_a4 Z,&AA_.9-,, • •� t i • �-� -[Lug! � 1 tq- -Ar + Z �� L-,a�NI 'L �c1i A ({�C(!k`Q�ar.S �' �, S�►+Ac�� S'Ca RKI.t>G 1pA S • New L�l�hea�l ( lea, Act& A,-f APPLICATION FOR SITE PLAN REVIEW Subdivision Plan LOCATION: ANR Plan Business Name: Mass Audubon Long Pasture Site Plan Assessor's Map# . 74 Parcel# 3-5 &3-6 Property Address: 345 Bone Hill Rd Cummaquid,MA 02631 APPLICANT OWNER OF PROPERTY Name: Same as Owner Name: Massachusetts Audubon Society Inc Address:•. Address: 208 South Great Road - Lincoln.MA 01773 Telephone: Telephone: 781 259 9500 Fax:. Fax: AGENT/ATTORNEY ARCHITECT/DEVELOPER/CONTRACTOR/ENGINEER Name: Same as.Architect Name: Jill Neubauer Architects, Address: Address: 15 Depot Rd - - Falmouth,MA 02540 Telephone: Telephone: 508 548 0909, Fax: Fax: •ZONING DISTRICT CLASSIFICATIONS STORAGE TANKS(HASMAT/FUEL OR WASTE OIL) District RF-.I Overlays) AP Lot Area 87,120 Sq.Ft. 2 Ac. Existing Unknown Proposed None Number Number Fire District Barnstable Setbacks(ft.) Size Size Above Ground Above Ground-. Front 30 Side 15 Rear 15 Underground Underground Contents Oil Contents Number of Buildings Existing 2 Proposed 1 Demolition 0 UTILITIES TOTAL FLOOR AREA BY USE: Sewer- ❑ Public ®Private Size 1000 gal Existin (SQ.Ft. Proposed (Sq.Ft. Water-®Public ❑Private (septic tank) Basement 450 Offices 2300 Electric- ❑ Aerial Underground Exhibit&Program 1100 1430 Gas= ❑Natural ❑Propane - Staff Housing. 700 , Detached Garage 940 Grease Trap- ❑ Size gal Gross Floor Area 5490. 1430 Sewage Daily Flow * 440 gal PARKING SPACES CURB CUTS Required Existing 1 Provided +/-.35 Proposed 0 On-Site To Close 0 Off-Site Totals 1 Handicapped Overflow in field +/-.75 * GP or WP areas restrict wastewater discharge to 330 gallons per acre per day into on-site system. f Old King's Highway Regional Historic District File# to be filed Approved'? CI Yes ❑ No Hyannis Main Street Waterfront Historic District File 4. N/A Approved? ❑ Yes ❑ No Listed in National and/or State.Register of Historic Places? ❑ Yes No Previous Site Plan Review File# Approved? 0 Yes ® No Previous Zoning Board of Appeals File# Approved'? ❑ Yes No Is the site located in a Flood Area(Section 3-5.1) Sue is;pi-ol)o.scd barilding i.s n<)t 1$ Yes ❑ No In Area of Critical Environmental Concern'? Site is,proposed building.is not. ® Yes ❑ No .Is the Project within IOW of Wetland Resource Area? ® Yes ❑ No Site sketch—informal presentation Yes ❑ No Site Plan prepared,wet stamped and signed by a Registered PE and/or PLS. p Yes No Parking and Traffic Circulation Plan ❑ Yes ® No Landscape Plan and Lighting Plan ❑ Yes No Drainage Plan with calculations and Utility Plan ❑ Yes ® No Building Plans,(all floor plans,elevations and cross sections) ® Yes ❑ No Note that all sip_nat=_e must be approved by-Code Enforcement Office at the Building Department Lot area in sq.ft. 260,463 sq. ft. Total Building(s)footprint 5,400 sq. ft. Maximum Lot Coverage as%of Lot 2.1 .. GROUND WATER PROTECTION OVERLAY DISTTICT REOUREMENTS: DISTRICT: AP Lot Coverage(%) Required N/A Proposed 2;1 Site Clearing(%)Required N/A ' Proposed 89.500sf=35%, PRINCIPAL BU.I1.13ING Existing House ACCESSORY BUILDING(S) New Visitor Center $r7 Yes❑ No Number of floors 2 Height: 23 ft, Number of floors 1 Height: 19 ft'. FLOOR AREA: FLOOR AREA: Basement 450 sq. ft. Second 1100 sq.ft. Basement . sq. ft. Second sq.ft. First 3000 sq.ft: Attic sq.ft. First 1430 sq.ft. Attic sq. ft. Other(Specify) sq. ft; Existing Detached Garage 940sf Please provide a brief narrative of your proposed project: New Visitor's Center,called the".Discovery Center" —1 420 sf,one story Reception/Exhibit area+2 Indoor Pfoeram rooms 2 ADA bathrooms R 2 small storage rooms New Qrading for ADA entry Rath from existing parking area I assert that I have completed(or caused to be completed) this page and the Site Plan Review Application and that, to the best of my knowledge., the information submitted here is true. . 4JA- ,1 ur o/.91�p1i.ccrnl Date 1L/V�l S.k.Q I S LR Printed Name of Applicant f• .S _....... Barnstable Harbor __..—— -_.. .... ............... . .. .. ...... Barnstable arbor —_L TRI T a ble H N ASSESSORS REF, OVERLAY DISTRICT. OO FL DZONE CD =`n X. / r+ ( �e 4 ! 8 8 REFERENCES n D 1 ,s, CAT'ON MAP � ZONE a�Le 2P ,6� _aye 3 O n.s Is a u d DIRECTIONS" ' i �a1 _ Cvdv r• OVERALL PLAN VIEW ,R ,po 90`r' .- .. :..., .. � .. w\Q'. LEGEND: ,; � ,�••• or oe.buon rm .- eo I w., r r i -----a;a rPomI Po,n 15 y tT Night Heron I \ I r 10 P C Arai /i w� / Y DETAIL PLAN VIEW No3E5: Pu[PAaEOTM: PPEPaaED6n ^^"L� . Site Plan Massachusetts Audubon Society Inc. r'i11gI000PIpg& Existing Conditions "" ;�".. �"' :" '"'«`•-" 208 South Great Road Sullivan n _��-•--"-"�w*e«" Lincoln MA 01773consulting-Inc At m. m w w, " �.�..•��®_m.� .�A� 345&382 Bone Hill Road Barnstable (Barnstable) Mass. W P - "`�"«'-"�„ "` "�• �" P,e;e.r: �soa, n,;,=,: �awe H March 5,2019 sue: As Noted r ` t EXISTING GARAGE <� TO REMAIN DEPOT IIENUE k, ci eL �MoutX M.o_ 510 I ; . ssavov •Lc \� EXISTING HOUSE ; =I^==^� TO REMAIN--------------- ' I ri - / f ` - �Pond ;7• PHASE l: •' � DISCOVERY CENTER ': is' '� � I k a t MASTER PLAN _ O r FUTURE-O-UT66OR'CLASS I L ---.— -- ' PROPOSED -- .. SITE PLAN --' i� ~ ' A000 `fI�1 �r y f m Long Pasture Discovery Center $& 5 5 Z Barnstable, MA u 3 y a 3 ei - ® - f c` > }. C v n ti t ® ' D =5 Long Pasture Discovery Center m 5 life Barnstable, MA N s m f 3 p � � � o O p „N Ir-ter' j .'. Six Do m� Long Pasture Discovery Center x Q s u Barnstable, MA r m 3 0 \ NORTH DORM O IS O =, D EXISTING HOUSE ` O � TO REMAIN m LMODiH MAR. 9 CWB LIVING. } - o DINING 5,9-OVOv 1 � 8 MEETING I A PRESCHOOL LONG SOUTH - I' PASTURE SHARED- DORM xSao-2SSI li -.. r [ItCHEN. ' o P ,F I ' SHARED Ilf .. haJlnarcn lecn MUDROOM 0 LP DIRECTOR ma,�nnec I I GREENHOUSE # Or+ lP STTAFFAFF _ + .�+,~ I- ENTRY v" 0 O RE4aEPilONB 1 ;ENTRY " ._ , ' ' �%HIBR Tex soe Ertvr Pur r, O , yl 1� h - PHASE l: "•. r>4r" - - m DISCOVERY CENTER 4 OCL— PROGRAM , A , r ' , �{ I Tw - MASTER PLAN L y: MASTER PLAN: F sr, F e.._i.-0.. •,% ,� z" =Y� UTURE OUTDOOR CLASS - fY r = r r' r r r„ , r , r I r. 3; S _ - - __ ll A011' rr , ` n n ` s o - s. 'i 4 n n O 3 ' - D O F �v f — 9 is _. -._......_.... '„ - I m Do 0 0 pp zi Long Pasture Discovery Center Om q cr 3 A Barnstable, MA 3 0 1 . ...- Y / \ i 1 a 1 • b l Q ray a� s t+ X':L` - S i - . a v t 1 r ' ' i _ X � - f „ .r1 1� Long Pasture Discovery Center 11 g 00 Barnstable, MA N � 3 - o tft ap o ap .. -m m } A '3 R k ® I JQ t � fa O SSx 1� F; 1 1 1 _.- -- " T ---- nite. . m MI nn m N N = 5 Long Pasture Discovery Centera Q 5 o e o o $ Barnstable, MA m g 3 • �i^ ylo I I ' I , >o � I I cO I O 3 � I • � I i A f §l r 5 I! 7771 WoLong Pasture Discovery Center � o 0 Barnstable, MA ti m i 3 r ml^ h a o n 0 - DI�I n .,t � T ` .._.... .::.,.. — -- , ' H �--- } t. :Stab Y [.....,. .-- { N = s Long Pasture Discovery Centertp o Q 3 i$' Barnstable, MA i 3 0 ^ • , III �® l I �r r � � Il • I F I .. _ ... .... ix r E. x V .. r a n �-n -- >o :o ----- 4p � :n 8 � A m AJ ----------_ - _ n m e v • Long Pasture Discovery Center HSp Barnstable, MA 3 ' V\ a c� w y Make application to local Fire Department. Fire Department regains origlnad application and issues duplicate as Permit. 331 - Dr 1 - 01�6� APPL10N- and PERMIT � M Fee: for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section,38A, 527 CMR 9.00, application is hereby made by:. Tank Owner Name(please print) Estate of Sherman Parke>x Signature t ap yutg orN—at Address 345 Berne Hill Rd . Fla rnatah7a MA 0 610 Street city State Z;� i . i Company Name Advanced Environmental ' Co. or Individual Print Print Address P .O .-.,Box 472 ,t1 Atlantic .Ave . Addf$ss South Dennis ,;PMA <;`. Print Signature (if applyin r permit) ,�ignat�re (if applying for permit) IFCI Certifie Other /f i ❑ IFCI Certified ❑ LSP# Other I Tank Location 345 Bone Hill Rd . BAr_ Tank Capacity(gallons) 1000 Sleet Address city Substance Last Stored Tank Dimensions (diameter x length) r. / 3 Remarks: v G I 6 r . . M- 77MMMI. , Firm transporting waste Advanced Environmenta]State Lic. r MV5083856100 i Hazardous waste manifest# E.P.A. # i Approved tank disposal yard J .G.Grants Co . Tank yard# 03501 Type of inert gas Tank yard address City or Town ric. 4111- /—/ 25 FDID# CIfZ147' Permit# Date of issue /—�(J. /p��7 Date of expiration i Dig safe approval number:. 9 7,!576 62FY,�' Dig Safe Toll Free Tel. Number-800-322-4844 Signature/Title of Officer granting permit Alter removal(s)send Form FP,-290R signed by Local Fire Dept..to UST Regulatory Compliance Unit, One Ashburton Place, Room 1310, Boston, MA 02108-1618. 292(revised 9/96) � Io 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property ' s 13,ne,Aw N ®fir owner' s name �����tl ® Mrs.Date of Inspection t:.:,htrw►oi Rrker JUL 18 1995 PART A HEALTH DEPT. CHECKLIST 70M, OFBARNSTABLE Check if the following have been done: %/ Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. A As built plans have been obtained and examined. Note if they are not available with N/A. r/ The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. ✓ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive' methods. The facility .owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. r' 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of, bedr'oom�s _L number of current residents os garbage grinder, yes or no laundry connected to system, yes or no _No seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: - AIIA t0d Oh '-OfCrj}l 0 _ Last date of occupancy GENERAL INFORMATION Pumpin records and source of in ormation: urfe'vt,, ( — oncr_ A �eAf MA lye) , - System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: S 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) Other (explain) Approximate age of all components. Date installed, if known,. Source of information: re //y Sewage odors detected when arriving at the site, yes or no L t 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / SYSTEM INFORMATION continued SEPTIC TANK: t/ (locate on site plan) depth below grade: (� material of construction: ii concrete metal FRP other(explain) dimensions: ll"d� c�fl`� ��%D s` 7� sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leaka e, recommendati n for repairs, etc. ) W0 i - n Kk7s oaf AZO re A9ir 5 (� CDn�j� DISTRIBUTION BOX:=/I/0 Oisf 6DA .-(locate on site plan) depth of liquid level above outlet invert Comments: ti (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number 4- leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : ,s0ei'h number and configuration e rC depth-top of liquid to inlet invert ` depth of solids layer depth of scum layer &one,j� dimensions of cesspool materials of construction ('en�etif _ 4,rrell BAnt indication of groundwater inflow (cesspool must be pumped as part of inspection) SQ0 o�cn der c� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; recommendations for maintenance or repairs,etc. ) o ,' i e-c- 41j2 rc 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, recommendations for maintenance or repairs,etc. ) r 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' N y � A Thy ., 57- N Y A 13 i � z 0 0 o 4 i O SS DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: (:r-Ade-, 4,o, h vtl 4)e(/ e;,2e- vh 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? /y Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? ' • number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? 1 within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? A/ within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. c I 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 1001 A � � 13AGK 6- T\ C , t"01 it QiMr X / DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation•//11 L _ 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? -b-/— _Discharge or ponding of effluent to the surface of the ground or surface waters? N Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped ,V Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? Al within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? Il within 50 feet of a private water supply well? N less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well .water analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector ERUCE MACALLIST'ER Company Name SHORELINE CONSTRUCTION Company Address 67 POND STREET � OST'ERVILLE, MA 02655 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: _� have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature � u Date �v�vE 30J lei IQ Original to system owner Copies to: Buyer (if applicable) Approving authority M i f i '��� M oIL r, 1 ' �s Y �.� �.� i � �I iJ I ^^� r I t i Y s i 3 /j imam St9�bC �i� IC*® 641 Mok Jr i Y I� I 1 I I 1 I • I � , 4 TOWN OF BARNSTABLE v LOCATION �'�(��t, e��:1 ` SEWAGE#Z 5,ot cTiv 4 VILLAGE -BA e nn I a U e ASSESSOR'S MAP& LOT -00 INSTALLER'S NAME&PHONE NO. :gry C SEPTIC TANK CAPACITY T060�A LEACHING FACILITY: (type) C'C°SSA4c61 (size) NO.OF BEDROOMS— BUILDER BUILDER OR OWNER 1/45- -5Xe Mi4A -//�/eee PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 1 q.• V 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'faci�ity) Feet Furnished by ` u / ',P� •_ l 3 1 B N u d n p�° co TOWN OF BARNSTABLE� UNDERGROUND FUEL AN/-lh3 '01D CHEMICAL STORAGE SYSTEMS' //�' j�) /A " Aa ASSESSORS MAP NO. PARCEL NO. ' 1 W /{1P�. `J ADDRESS: _9Y,5_ tDOrvff- plu- RoAp VILLAGE-' CUMA74000 F 14AME;._.... CONTACT PERSON 75(P, �'� �� �af' PHONE NUMBER :3 LOCATION OF TANKS: . CAPACITY: ..TYPE- OF- FUEL AGE: TYPE: LEAK ( 1 OR CHEMICALS DETECTION S`�e C©iz vM-_ OF HOW ,�C�� AF L\?J HM-ri AIC 0 1 L 3220 5-r SYSTEM' Aid Lc�ta,9 kKBQS IvOM ° �,� 7141$ Tig AjK Oy7Pr NO LOYVC, i2 7 rV ' S j 64L IYM71,416 OIL M10 5- 7z-M. AW-0 !t= �gics< i-xt DATE OF PURCHASE OF EACH: 10 Iti5 f 3. 4. 5. �'rR '� T. DATE OF FIRE DEPARTMENT PERMIT: jT' j � j � FA70R TESTING CERTIFICATION SUBMITTED: - PASSED DID NOT PASS Ins s rlva ms A J e—K,4 v® PAre- ® C^lwv01V_50A;9 Pr l L 1 1910 -r/9N ei ME- Ftaori F.W,Ltj r3 L PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. Imo' ., t, � � �� �� � � � �� � . -.--��^, � �./� �� �� _ � � �� . � � , i n � � � � ��� g �� ���1 � � �� �t i Barnstable Harbor soh uuav ASSESSORS REF.' t r VE ELEV IJ.e_ Mop 74.Parcel 3-5 h 3-6 Barnstable Harbor - _ AMA ZD'' - J471s• OVERLAY DISTRICT: �= N89'J$'S8• 91.59' W E c' ` qp_ARui/er Protection District (t•i�� t�pr 18'tU ) - FLOOD ZONE: Ob Arco eon \ / In. - - L X(Mm Flood No W 'a Top"!�— .'' O AE Ele,12.ev&1J'.AE Slay.IJ. :�..:.^u¢,)= e L.1,' ) (Min Coastal Bank M X(Min.Flood He.) ••�,` �..� - ry #250001C­r110559nJ No. \t`I.�K_- �•��± •..r,. July16,2014 t�i _ 50' ..-._ - . c — \ ®roK ( :8 c REFERENCES: •r °' '' Deed:Cu7620(Lots 6 15) ^LOCATION MAP �.2?....-. ( Flagged/ `�•0 porn CIJ7619(Lots 5 h 14) gyly (1•=20003 J /Brush Lina I\ �•L-- — Plan:21BSfE(Record Lets 14 B 15) \ 2185IA(Record Lots 5 h 6)— — m / / I r--•f HSE ° ZONE: _ Lot 14 Al - ,-�-� iw ( / ll RF-1 / 6 // ,``i1 Area(min.)M) Sc(RPOO) Q00 •E .111,nin)'12 20' 5' 5etbac Front JO' / / 100' \ /`,I/ NB3'rJ2.01•E Side 15' tine eew,4\ q��� d O"5�`h ' J76.A1 O Rear 15' \ s R6-- rn - PP[ o ,I,BS�,���F�p�Je 'l Q DIRECTIONS: �y� t( nn Lot 15 From Hyannis-Follow Main Street dnd tum right onto I \ Loan _ —2r-- \ 3i' E+( OVERALL PLAN VIEW Ba.,aatt Lane.Gantmao et.oigbt onto soar:aa way.r m - \ Right an Enterprise Roatl la straight Ti through the Scale I•.120' right coon onto Independence Drire.ht t left onto Mary 45• 6J7.A1 Dunn Roatl right to Main Street(RL 6a).Tum left '30•W to on Hgland on Road. Lye r — �- \ \ \ 572� 13459 is t the and on the left. --too.�sLfr� / / / \ \ �00 LEGEND' C \ / / /J / �O \\ \ \ a CDT Cedar Tree HT Holly Trea DT Deciduous T m Gas Play -G- 'Area ` \ \ H'a Wetand nag • \ \ / / ` / '�. ,�5M.H �_ -'/ q/ J / \ ` G Light Past \ El CB H _O CAread \ / \ / \ ` - —OHW— (verhead W...•..�2'2-- ✓ —25— Eiewt/an contour T / / / / /` � / // �- .�•_-25�_ --.-._ C2 S`rVW'Zr \ Barn J�J - 2e-- __ ` P kin9 b �J� ./ \\ B r M1 Lhra Q. \ I l Lawn \ _ \5a0• de, \ B B.Halt on by j'�C�.�� / I- I l \ Cra gel Driw 1 �/ 211912019 `i I I I , 8 (// Growl D Ys I I I `i_ � \ � Heating 1N� _ ___i_I___ �-MII \ \ \) - Od Tonk / ' X-"M1i / \ / i Grow/Or/w I I Lt—J I I I �P.J1. vaux #345 2 l J I J ed \(a 2 sty 0w 11ing i I I I I I I 'Ili I'111 II� \ 21.3 5111 r Cobble Night Heron fff en I I Pond i I I I name a �etaeer I I N • rc� � / 1 / / I ' I Gard G-een 1111 f I / �I I H ar lr µ. I BYW I Lawn va <`%g�` I ` ` • // �/ crawl P Hring /{I B"en Lina �rr�l I i I / I I I I M1` /�1``// ✓ - - - - Fide Ham\s� ` \ N72 •E+ I J I I f T «( J50'Y fa \ \ \\\ Poss31e Wetland �' d J16.4J' DETAIL PLAN VIEW NOTES PREPARED FOR: I PREPARED BY.' TIRE: Site Plan Scala 1•=20, , I)the structures spawn were located on the ground by conwntlonal Massachusetts Audubon Society Inc. Suilivanc' ngineering& Existing ConditionsrwymethodFebruary 26, 6.2 topographic infannotion and gbaundry location ware tablished sing RW CPS on ar between r7L,February 19. ty lindFebruary 26.2019. LOS SaUth Great Road o nsultin lRC. At 2)Theproperty line n.ti.rotion spawn hereon waa aampped T.am Lincoln MA 01773 ' awname recore mmrmatran. J)The datum used is NAVO 1988. at by RTK GPS. IT (50M42 secie•P.O,slat 1n. •711 Main Street,Gn81n-lla,nw 02655 345 & 332 Bone Mill Road secl®suIlWBnengln.com•wwwsullivpnfmgln.com Mass. ~4 Structums located ore of to the aura around the maln 120-Owmp 0 BD ' 120 240 aeo Oraft: CTR Field: rn JOD CTR Bastable Barnstable w pupping at 345 Bone Hill Read.Other structures may the 20-OetaO Plan p 7p 20 40 80 _ property,bu!were not located as port of the scope of this'a survey. Review: 3CTR90 Comp.: CTR DATE: March 5,2019 SCALE. As NotedLn Project:, 39003 Project: Audu6on_Bone Hlll • NEUBAUER 15 DEPOTAVENUE FALMOUTH,MA 02540 508 548-0909 FAX 548-2552 " Jna(Pjnarchitects.com Jnarchitects.com . W nl� W U � Q , N m O stuns i�isaea�a�i� 5n7m9 SITE AXON ,j A001 i" V E VW 'epolswoo Z p N o o IMy�IJf 2aa�ua3 Aian03sia aan�sod buoy. o Q M ip- • 1 w ^l — l��r � 0 , ®r - "' Lmll N �V e v , U ,;1 r� a •IL ... 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