HomeMy WebLinkAbout0235 BOULDER ROAD - Health 235 BOULDER RDAO
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Commonwealth of Mass
achusetts
6 L1%I
Rai Title 5 Official Ins '„'ec '
a Subsurface Sewage Disposal System Form-Not for O n Form
or Voluntary Assessments
235 Boulder Rd.
Property Address
George Layton
t n
Owner Owner's Name r
Information Is ?
required for every Barnstable MA 02630
page. clty own 7/16/2019
State Zip Coda Date of Inspection ti
Inspection results must be submitted on this form. Inspection forms may not be altered in n
way. Please see completeness checklist at the end of the form. y
Important:When A. Inspector Information
filling out forms `
on the computer,
use only the tab Dou las Brown
key to move your Name of Inspector
cursor-do not
use the return Cape Cod Se tic Services Inc.
key. Company Name
q� 350 Main St.
,ae Company Address
West Yarmouth MA
i? City/Town 02673
508-775-2825 State' ZIP Code
Telephone Number SI4297
License Number
B. Certification r
I certify that: I am a DEP approved system inspector In full compliance with Section 15.340 of Title 5
(310 CMR I5.000); I 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
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
' Y
Ins ors S(gna ure - - 7/29/2019
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.
t6lnsp.doo•rev.7/2e/2016
Title a o flalal Inspection Form:Subsurface Sewage Disposal System.page 1 of 1s
Commonwealth of Massachusetts
,T Title 5 Official Inspection Form
fi Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Boulder Rd.
Property Address
George Layton
Owner owners Name
information is
required for every Barnstable MA 02630 7/15/2019
page. Citylrown
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:
System in working condition.
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 2 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments
ents
235 Boulder Rd. :
Property Address
George Layton
Owner Owners Name
information is
required for every Barnstable MA 02630 7/15/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant.)
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 (I 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.7126/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
!� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
0
235 Boulder Rd.
Property Address
George Layton
Owner Owners Name
information is -
required for every Barnstable MA 02630 7/15/2019
page. Cityrrown
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.
❑ 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 cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
I
Commonwealth of Massachusetts
Title 5 Official In ection Form
Ala Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ssments
235 Boulder Rd.
Property Address
George Layton
Owner Owners Name
information is
required for every Barnstable MA 02630 7/151/2019
page. City/Town 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 due to an overloaded
or clogged SAS or cesspool
® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year'NOTdue to clogged or
obstructed pipe(s).,Number of times pumped:
❑ ® Any,portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool,or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence-
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A_copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 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 CA.
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 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.e' 235 Boulder Rd.
Property Address
George Layton
Owner owners Name
information is
required for every Barnstable MA 02630 7/15/2019
page. CitylTown
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 al/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?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the-site inspected for signs of break out? -
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered,-opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in'the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
,9 Title 5 Official In Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;u 235 Boulder Rd.
Property Address
George Layton
Owner Owners Name
information is Barnstable required for every MA 02630 7/15/2019
page. Cityfrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x3=
Description:
330gpd
Number of current residents: Unknown
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
information in this report.) 0 Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 2017=82gpd
Detail:
2018=88gpd
_
Sump pump?
❑ Yes No
Last date of occupancy: Unknown
Date
l5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
I
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y
,�,• 235 Boulder Rd.
Property Address
George Layton
Owner Owner's Name
information is
required for every Barnstable MA 02630 7/15/2019
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):
Gallons 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 readings, if available:
Last date of occupancy/use:
Date
Other(describe below):
3. Pumping Records:
Source of information: No Records
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 a of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
235 Boulder Rd.
Property Address .
Georg e Layton
ton
Owner Owner's Name -
information is
required for every Barnstable MA 02630 7/15/2019
page. Cityrrown State Zip Code Date_of Inspection
D. System Information (cont.)
4. Type of System. t
® Septic tank, distribution_box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool '
Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ 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:
2011 Per BOH Records.
Were sewage odors detected when arriving at the site? El Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade:
37" ..
feet
Material of construction: r
❑cast iron ®40 PVC ❑other(explain):
Distance from private water-supply well or suction line: +10,
feet
Comments (on condition of joints, venting, evidence of leakage,etc.):..
Line checked with sewer camera and was found to be clean, properly.pitched with no sign of root
intrusion.
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 9 of 18
., Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�u 235 Boulder Rd.
Property Address
George Layton
Owner Owners Name
information is every Barnstable MA
required for eve 02630 7/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 27"
feet
Material of construction:
® concrete ❑ metal ❑fiberglass 9 El 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: 1000Gal
Sludge depth: 2-4"
Distance from top of sludge to bottom of outlet tee or baffle
1"
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? Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Inlet
cover 3" below grade with outlet 27" below grade.
t5insp.doc•rev.7/262018 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
i
I
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 235 Boulder Rd.
Property Address
George Layton
Owner Owner's Name
information is Barnstable .required for every MA 02630 7/15/2019
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:
❑concrete ❑ metal ❑fiberglass g ❑ polyethylene [].other(explain):.
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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 ❑ polyeth lene
Y ❑other(explain):
Dimensions: '
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t> Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Boulder Rd.
Property Address
George Layton
Owner Owners Name
information is Barnstable required for every MA 02630 7/15/2019
page. Cityrrown 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.):
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 distribution to out equal,any evidence of solids'carryover, any
evidence of leakage into or out of box,.etc.):
H-10 DB-3 with 1 line in and 3 lines out in good condition. Box is clean and'level with minimal solids
carryover. Outlet inverts equal with speed levelers in place. No sign of overloading or hydraulic
failure. Cover 16" below grade.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form - Not for Voluntary Assessments
235 Boulder Rd.
Property Address
George Layton
Owner Owner's Name
information is
required for every Barnstable MA 02630 7/15/2019
page. City/Town 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: El Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
"If pumps or alarms are not in working order, system is a conditional pass.
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: 24-Quick 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑,� innovative/alternative system
I
Type/name of technology:
l5insp.doe rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Boulder Rd.
Property Address
George Layton
Owner Owner's Name
information is Barnstable required for every MA 02630 7/15/2019
page. City/Town State Zip Code
Date of Inspection .
D. System Information (cont.)
11. Soil Absorption System (SAS) (cost.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
24-Quick 4 infiltrators. No standing effluent in units during inspection. No sign of overloading or
hydraulic 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 ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure,1evel of ponding; condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for V oluntary Assessments' x
235 Boulder Rd.
Property Address
George Layton
Owner Owner's Name
information is
required for every Barnstable " MA 02630 7/15/2019
page. City/Town State. Zip Code Date of inspection
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.):
r .
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection . Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
; y 235 Boulder Rd.
Property Address - ,
George Layton
Owner Owners Name
information is Barnstable required for every MA 02630 7/15/2019
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
f
Commonwealth of Massachusetts
�e Title 5 Official In Form
a
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
235 Boulder Rd.
Property Address
George Layton
Owner Owners Name
information is Barnstable required for every MA 02630 7/45/2019
page. City own State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: +5'from sas
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: 2011
Date
❑ Observed site(abutting property/observation,hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test hole data and engineer certification on file at,BOH.
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
235 Boulder Rd.
Property Address
George Layton
Owner Owners Name
information is Barnstable required for every MA 02630 7/15/2019
page. City/Town
State Zip Code Date of Inspection
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
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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Page 1 of 2
TOW�NN OF BAMSTABLE
LOCATION S. cJIGL@Q SEWAOE#�1X''5 C\
VU-LACE ASSESSOR'S MAp&PARCEL E—
INSTALLER'S NAME&PHONE NO._� 1�i C�t�Q�S - o
SEPTIC TANK CAPACITY— (Qp y
LEACHING FACHM Y:(type)_ �C K C!C (size)
NO.OF BEDROOMS
` . . OWNER _ I
PERMIT DATE: J COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Welland Leaching Facility(If any wells exist on
sitaor within 200 feet of leaching facility)
Edge of Wetland and LeachingFacie —Feet
Facility(If any wetlands exist within
300 feet of leaching facility) ,
.
FURNISHED BY Feet,
00 ,3
t 1
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https://townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mapp... 6/28/2019
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
(.n
°f 235 Boulder Road, Barnstable M -315 P-36 Icy
Property Address t:A
George Layton
Owner Owner's Name 5:"I
information is 235 Boulder Road Barnstable ✓ MA 02630 September 17, 2015
required for every �
page. Citylrown State Zip Code Date of Inspection f
r'b�t
h�
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Troy Williams
use the return key. Name of Inspector
Troy Williams Septic Inspections
Company Name
19 Hummel Drive
Company Address
South Dennis MA 02660
Cityrrown State Zip Code
(508) 385- 1300 S1682
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
c
September 17, 2015
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�s
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal ystem•Page 1 of 17
r ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is 235 Boulder Road, Barnstable MA 02630 September 17 2015
required for every P ,
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
found®
1 have not d any information o mation 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:
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
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-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,.•�''� 235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is required for every 235 Boulder Road Barnstable MA 02630 September 17, 2015
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑•Y ❑ N - ❑ ND(Explain below).
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is required for every 235 Boulder Road Barnstable MA 02630 September 17, 2015
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is 235 Boulder Road, Barnstable MA t 02630 September 17 2015
required for every p ,
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Boulder Road, Barnstable M-315 P-36
Property Address
George Layton
Owner Owner's Name
information is 235 Boulder Road, Barnstable MA 02630 September 17 2015
required for every p
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
'Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3113 Title 5 Official Inspection Forth: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
235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is required for every 235 Boulder Road, Barnstable MA 02630 September 17, 2015
page. City/Town State Zip Code Date of Inspection
D. System Information t
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 14=48,000 gals.
g ( y g (gp )) 13=49,000 gals.
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/industrial Flow Conditions: w
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
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: N/A
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is 235 Boulder Road, Barnstable MA 02630 September 17 2015
required for every p ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
N/A
General Information
Pumping Records:
p 9
Source of information: Last pumped in January 2015 per info from owner.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
Single cesspool
9 P
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system b system operator under contract
P Y Y Y P
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
upTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is 235 Boulder Road, Barnstable MA 02630 September 17 2015
required for every P
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
D-box and leaching were installed to existing tank on 12/28/11 per compliance.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"+
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.):
Lines were found clear at the time of inspection.
Septic Tank(locate on site plan):
2.5'with riser to 4"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
5'X9'X6' 1000 gallon
Sludge depth:
4"
t5ins-3/13 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
M ,••''t 235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is 235 Boulder Road Barnstable MA 02630 September 17, 2015
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
2' 8„
Scum thickness none
Distance from top P of scum to to of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined?
probe/measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pyc inlet and outlet tees were found present and in working order. No evidence of leakage or damage
was found. Tank was not in need of pumping at this time.
Grease Trap (locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
t5ins-3113 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
y 235 Boulder Road, Barnstable M-315 P-36
Property Address
George Layton
Owner Owner's Name
information is 235 Boulder Road, Barnstable MA 02630 September 17 2015
required for every p ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
N/A
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm and float switches, etc.):
N/A
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
ect'
on Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 235 Boulder Road, Barnstable M-315 P-36
Property Address
George Layton
Owner Owner's Name
information is required for every 235 Boulder Road Barnstable MA 02630 September 17, 2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert level
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was found level and in working order with equal distribution to outlet lines. No evidence of
backup in the past was found at the time of inspection.
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.):
N/A
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is 235 Boulder Road, Barnstable MA 02630 September 17 2015
required for every p
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 24 Quick 4's
❑ leaching galleries number: 42'X 18.5'X 1'
❑ 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.):
No evidence of hydraulic failure or problems in the past were found at the time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool
N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Forth: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
235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is required for every 235 Boulder Road Barnstable MA 02630 September 17, 2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy(locate on site plan):
Materials of construction: N/A
Dimensions
N/A
Depth of solids N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t5ins•3113 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
235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is 235 Boulder Road, Barnstable MA 02630 September 17, 2015
required for every p
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Ww}v l•.y„
L� S
3 � g3
z
3
t5ins-3/13 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
.' 235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is required for every 235 Boulder Road Barnstable MA 02630 September 17, 2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15+
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: 12/8/11
Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database -explain:
AIW 247 Zone C 24.3' 4.8'adjustment
You must describe how you established the high ground water elevation:
Test hole recorded on plan showed no water found at 13.5'. Hand augered 5' below bottom of
leaching with no water found at a depth of 11.0'. Groundwater adjustment at the time of inspection
was 4.8'. Bottom of leaching at 6.0'was found not to be located in the high groundwater elevation at
the time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Boulder Road, Barnstable M -315 P-36
Property Address
George Layton
Owner Owner's Name
information is required for every 235 Boulder Road, Barnstable MA 02630 September 17, 2015
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION S ( ov( 2 ( SEWAGE# //— `�
VILLAGE_O/ a2! >� ASSESSOR'S MAP&PARCEL S
INSTALLER'S NAME&PHONE NO. n" heAL \ eZ 6 " ®
SEPTIC TANK CAPACITY 100 0
LEACHING FACILITY.(type) (size)
NO.OF BEDROOMS
OWNER , (Jr
PERMIT DATE: COMPLIANCE DATE:
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
o '
c-
bpi
03 C�K),o `
u
No. y�, :4 ;} Fee d
THE COMMONWEALTH OF MASSACHUSETTS i Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARN$TABL'E, MASSACHUSETTS Yes
Zippliratiodfor Zisposar 6pstem ContCUttion permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ��� 'd a Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 3(S— r C�'� ,q 4
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Gt �00o?`�G—a WeS Sv
Type of Bu' ing: Q
Dwelling No.of Bedrooms Lot Size .3 .� t. sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33 U gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title o .
Size of Septic Tank /ODp Type of S.A.S. ON y(//'GW 7 5
Description of Soil (G6 ,�� v lnfi f 5AYL 1D r fi
Nature of Repairs or Alterations(Answer when applicable) ( ok- ep le
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 lace the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by _. �l 2 Date
Application Disapproved by Date
for the following reasons
Permit No. aic) I l L4 3 2, Date Issued 7i_��,
✓56 �w�f � �-.. ,ram k '. .
' No.g V ?/ -�-- x n ;, Fee O
..._.T;....:
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
?Q Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNS*a6E, MASSACHUSETTS
m r
01pplitation, fOT tBtlosal *pstpm Cottstructton Vamit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel..No.
�� "
Assessor's Map/Parcel 3/S- (� i� 14 C. jzA0I
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
' �aS�Ry6-SW-0
Type of Buil ing: Q (,
Dwelling No.of Bedrooms Lot Size 3��-1 1[/ A.ft. Garbage Grinder( )
i
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) f3 O gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /070 Type of S.A.S. 2?4j Vt-Cf< S
i
j Description of Soil I C6
I�
Nature of Repairs or Alterations(Answer when applicable)
t
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
r accordance with the provisions of Title 5 of the Environmental Code and not to ,lace the system in operation until a Certificate of
Compliance has been issued by this Board of Health. !
Signed I Date Pee
i Application Approved by Y-v\ VIYI-C_ Date
Application Disapproved by Date
for the following reasons
Permit No. fl ( I Date Issued
------------------------------------------ --------------- -----
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
CPrtiftratr of Compliantr
THIS IS TO CERTIFfY,that the On-sit Sewage Disposal system Constructed( ) Repaired
Abandoned 1 S
at ��23 0111,11%e__ RI> has been constructed in accordance 11
with the provisions of Title 5 and the for Disposal System Construction Permit N . dated
Installer R2lny Designer tp'S Sv �e -y
#bedrooms Approved design flow ./3 gpd
The issuance of this permitshall not be construed as
a guarantee that the systeT ill functi des g ed.
` Date (�// / Inspectors
No. Fee b 1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
mispo8aY 6pStem Dtt�tCULtton permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at �6, /
26i � p
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction(must be completed within three years of the date of this permit.
Date s" 1 ' Approved by rvl_V'Y\�G
e
Town of Barnstable
Regulatory Services
. Thomas F. Geiler, Director
enttNsi'AsL.E.
Mom. Public Health Division
At,<n �. Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form L n 3 l C1 AIL.
Date:
Designer: U(2-Jt=P_( Installers —
Address: `� �� Z / Address:
Iw
On �� ,Y`e was issued a permit to install a
(date) (in taller)
septic system at 23 �`� `c�`eV N based on a design drawn by
(address)
t,oF3M't,z dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
,tN OF Mqs 9 y
L �o DAVI A0D c�N
(Installeo Signature) o D.
FLAHERTY, JR. N
No. 1211
10
}� 01STES
{IDesigner's Signatur / (Affix D amp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q: Health/Septic/Desiper Certification Form
down cape engineering, inc. SIEVE SOILS ANALYSIS 235 BOULDER ROAD BARNSTABLE, MA
DATE OF REPORT:12/14/11
.JOB : GRAIN SIZE ANALYSIS-SIEVE TEST r
SITE: 235 BOULDER RD BARNSTABLE, MA
LOCATION: EAS SURVEY TEST HOLE
? SIEVE ANALYSIS Weight Sample(Grams): 232.5
SIZE :WEIGHT RETAINED : % RETAINED : % PASSED
(sum)
1" 0.0; 0.0%! 100.0%
0.0 0.0%! 100.0% .
--------------1................. ..A-----------^-•- _.»L-»- --------^----
1/2" 0.0: 0 0%: 100.0%
--------------}---------------- r--------------•------r-----^------------
10
--I..........................y--------^^-----------r----•--•-•--0.0%
#4 ; 0.0; 0.0%; 100.0%
-----------••-........................... ...........---- I............._.._.
#1013.3; 5.7%: 94.3%
------------- ............ a-------------------- ...........----
#20 55. .a------------------o-}-••----•---•----o-
#40 123.5: 53.1 /o; 46.9/o
Au----.-». ........................- ---------..»-------...f.........'......___
#50 156.5; 67.3%; 32.7%
-------------,.. ..... ------------------...........
............
#80 195.3: 84.0%: 16.0%
--------------------------------------------------------------•..................
#100 205.3; ' 88.3%: 11.7%
--------------.................... ..A--------------------- -----------------
#200 221.3: 95.2%� 4.8%
_-------------}................... ..}.- ..-•-------.-....-r-..-»---•--...---
PAN: . 230.5; 100.0%; 0.0%
SAMPLE: 232.5;
NOTE:TEST ON PASSING#4 ONLY, 5.9% RETAINED ON#4 <45% O.K.
RESULTS:
SOIL CLASSIFIED AS AASHTO A-3 (GRANULAR, MEDIUM SAND)(UNCOMPACTED)
PERCENTAGE OF MATERIAL PASSING#4 SIEVE :
#4 100% (TEST ONLY MATERIAL PASSING#4) OK
#5010%-100% OK
#100 0%-20% OK
#200 0%-5% OK
SAMPLE MEETS TITLE 5 FILL SPECIFICATION
>98% SAND
RESULTS: PERMEABLE MATERIAL-CLASS 1 <2 MINJIN. MATERIAL �,� N oFMgSs
NONCOM PACTED �� e�
SOIL DESCRIPTION: MEDIUM SAND WITH SOME SILT DANIELA.
OJA.LA
CIVIL
o �No.46502
S� NAL /
I
down cape engineering, inc. 'SIEVE SOILS ANALYSIS 235 BOULDER ROAD BARNSTABLE, MA
DATE OF REPORT:12/14/11
JOB : GRAIN SIZE ANALYSIS-SIEVE TEST
SITE: 235 BOULDER RD BARNSTABLE, MA
LOCATION: EAS SURVEY TEST HOLE
SIEVE ANALYSIS Weight Sample(Grams): 232.5
SIZE ;WEIGHT RETAINED % RETAINED % PASSED
(sum) '
1" 0.0; 0.0%: 100.0%
3/4" 0.0� 0.0%: 100.0%
11/2" 0. -----------------
T---------------------r------------------
3/8" 0.0; 6.0%; 100.0%
--------------;.......................
.. --------------------- ------------------
#4 0.0' 6.0%: 1 QQ.0%
------�- ---------------------------------------- To/-o........•-----------
#1 Q 13.3; 5.7% 94.3 0
#20 55.1: 23.7%:
•-------------i..........................A--------..-...-------..-i.--.-..-._........
#40 123.5. 53.1%,,
•------------- ....................
#50 156.51 67.3%;
------------;................................----------------•----------- -- -•-
#80 _ _ 195.3' _84_.0%:
#100 __-- -�.....................
. ... ........... 205.3;_____-_----- 88 3%,' __— 11.7%
------- - •-- ---- --------- -------
#200 221.3: 95.2%: 4.8%
PAN: 230.5: 100.0%; 0.0%
SAMPLE--- ----------------------- ---------------------------------------
i
NOTE:TEST ON PASSING#4 ONLY, 5.9% RETAINED ON#4 <45%O.K.
RESULTS:
SOIL CLASSIFIED AS AASHTO A-3 (GRANULAR, MEDIUM SAND)(UNCOMPACTED)
PERCENTAGE OF MATERIAL PASSING#4 SIEVE :
#4 100% (TEST ONLY MATERIAL PASSING#4) OK
#5010%-100% OK
#100 0%-20% OK
#200 0%-5% OK
SAMPLE MEETS TITLE 5 FILL SPECIFICATION
>98%SAND
RESULTS: PERMEABLE MATERIAL-CLASS 1<2 MIN./IN.MATERIAL ��tt�oF�Ass
NONCOMPACTED �
c
SOIL DESCRIPTION: MEDIUM SAND WITH SOME SILT °� DANIELA.
o OJA,LA
CIVIL v,
q No,46502
N 1-
A
i
of
Town of Barnstable P# �a
Department of Regulatory Services J/
Public Health Division Date
M AE&
200 Main Street,Hyannis MA 02601
� -/ � � �/� ► o =
Date Scheduled 1� Time—,L—_ Fee Pd. �
Soil Suitability Assessment for Sowiwe Disposal
Performed By: �1 Witnessed By:
�L����
LOCATION& GENERAL INFORMATION
Location Address Owner's Name lam- .r
77 9l LJ�
IA �� Address
Assessor's Ma /Parcel: �,
P �j��'� ?J�j Engineer's Name ��
NEW CONSTRUCTION REPAIR Telephone# —�2rj— �j(glft7
Land Use: �J� 'P 5 , o �zs.swve•�, Ob , 6�
J Slopes(96) Surface Stones
Distances from: Open Water Body ! ft Possible Wet Area__±_�Cft Drinking Water Well �
nn �
Drainage Way��rft Property Line ft Other /,d� 3p ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands f'n proximity to holes) \
• sue_
(y.
Parent material(geologic) 2 GG�1�slt^!'//C$y �� Depth to sedroek N
Depth to Groundwater. Standing Water in Hole: ! P Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: //
Depth Observed standing in obs.hole: 16z,f In, Depth to soil mottles: �a In.
,
Depth to weeping from side of obs.hole: _ _ in, Groundwater AdJurtttnent �� ft. ��
Index Well# Reading Date: �� Index Well level Adj.factor Adj.droundwater Livel ;>AW
PERCOLATION TEST bate�Z Tbne 1v 4
Observation
Hole# l � Time at 9"
Depth of Perc dl'�1 � Time at 6"
Start Pre-soak Time @ / Time(9"-6")
End Pre-soak G— Zyf�L
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) N�
Original: Pubic Health Division Observation Hole Data To Be'Completed on Back---------
***If percolation test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
DEEP-OBSERVATION HOLE LOG Hole#� /ZG .4
Depth from Soil Horizon Soil Texture .Sdil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
Consistcricy.%Gravel)
�G �� G �•,� °Y2`// e
61
" �L •��� d�l v Gin • tl--c
DEEP OBSERVATION HOLE LOG Hole# Z 112 S;o
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
onsis en %Grave
J 7.1" 2 5
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistencv.%Gravell
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,
e
:M R Flood Insurance ate a
ICI p
Above 500 year flood boundary No_ Yes K
Within 500 year boundary No Yes
Within 100 year flood boundary No.,_,_.. Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervio s aterial exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring per ious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required trainin exper'o 7andeer en d s Abed in `10 CMR 15.017.
• Signature Date • '
QAS.EPTICTERCFORM.DOC
. t
Y TOWN OF BARNSTABLE
x N„ ��1�1�ei_ t
LOCATION SEWAGE # 72J
3
VILLAGE �l d9y`"Ja� ASSESSOR'S MAP& LOT .3/5`eV
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS J
BUILDER OR WNER>
PERMTTDATE: /�// �7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 571 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) ///w Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) /� Feet
Furnished byL.Z
.�
�� ��
� � i
� � ;
` �
��
�:
G
' V � j
i
i
i
9.::
Ci'.
"• n,
i�- �_
� _
y, � LL
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppCication for Miopozal bpetem Cott!truction Permit
Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System e1ndividual Components
Location Address or Lot No. 13 5- Q 10,44110, d/- Owner's Name,Address
ddress and Tel.No.
Assessor's Map/Parcel G ��N
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(./0
Other Type of Building g&,2ZYeWKeNo.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank l Af Type of S.A.S.
Description of Soil /lox
Nature of Repairs or Alterations(Answer when applicable) -A
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b his Ho f 11fifilth.
Signed Date
Application Approved Date ►-�
Application Disapproved for the following reasons
Permit No. < Date Issued �`
3 f 5 -- 1
Fee
THS' entered in computer.COMMONWEALTH OF MASSACHUSETTS� a
es
,PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ✓
F
2pplication.for ;migpozar bpotem Construction erntit
Application for a Permit to Construct( )Repair(v )Upgrade( )Abandon( ) ❑Complete System eIndividual Components
Location Address or Lot No. �J®y/��` r� Owner's Name,Address and Tel.No.
`7 In®1'I 50*eTs
Assessor's Map/Parcel (if_-,ra /Q e
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms�3 Lot Size' sq.ft. Garbage Grinder( d
Other Type of Building ;/_/�P_.5/Gl'G'���No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow J� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /00® e.-71 Z�671; q Type of S.A.S.
Description of Soil /D il' ,7j�iY�
Nature of Repairs or Alterations(Answer when applicable) �^�✓ ,1�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b s o f Health. Z i
Signed Date
Application Approved Date r
Application Disapproved for the following reasons
a lPermii No. ' Date Issued
—
THE COMMONWEALTH OF MASSACHUSETTS �J 5 O �
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that he On-site Sewage Disposal System Constructed( )Repaired(�)Upgraded( )
Abandoned( )by !/D` h
at D Allhlflee` !' /`I 5 f4>Alf has been construct dj'n acc dance
with the provisions of Title 5 and the for Disposal System Construction Permit No dated � /
Installer Designer r► n
The issuance of of be construed as a guarantee that the ill,function as c 'sign ��
Iff
e W
Date Inspector A
VN9
----------------------------� --------
No. l/ —� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Misposai 6pstem onstruction Permit
Permission is herebyranted to Construct air ✓ rade Abandon
g ( P ( ) Pg ( ) ( )
System located at J— e
2 'i7 57W P
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this 't.
Date: v Approved b
y .
„ U6199
NOTICE: This Form Is To`Be Used For the Repair Of Failed
Se--tic`S04111s Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
A4el O- Xiereby certify that the application for disposal worsts -
construction permit signed by me dated /f///qfl' concerning the
property located at Z O®l!/a4i^ �"� A-Ire. �Ijx4eets all of the
following criteria:
The failed system is tonne✓ed to a residential dwelling only. There are no commercial or business
es associated with the dwelling.
�e c
soil is classified as C-T.A S I and the pe:coiaticn rate is less than or equal m : minutes per inch-
here are no wetlands within 100 feet of the oronosed sentic.system
There are no private wets within 150 fee;of the proposed septic system'
(�There is no incense in flow and/or change in use proposed
IP/Ther e are no variances requested or needed
The bottom of the proposed leaching tY facili will not be located less than five feet above✓the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the rrimptor
ethod when applicable]
If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the ma-durum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 1 3
B) G.W.Elevation Z 7+the MAX High G.W.Adjustment.7 l _
DIETERENCE BETWEEN A and B b
SIGNED DATE:
:
7
(Sketch proposed plan of system on bac:k].
4F heft dollar.an
. i
O
i
O O
IK`
TOWN OFBARNSTABLE
LOCATION Z35_,606'02r rOr® SEWAGE #
VILLAGE A-,re5t�,41� ASSESSOR'S MAP & LOT 315-D36
INSTALLER'S NAME&PHONE NO. o/;to�orSt/
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS J3
BUII..DER OR WNE� 5 d''n
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S` Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 1,/�/9 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) /:%j` Feet
Furnished by
s
s
hd CF `' ION SEWA GE PERMIT NO.
� 35; i to u IJ eg- tZ4 96 — 1770
VILLAGE
aA)
IN`STA LER'S NAME A ADDRESS
N
it \ it
S U I L D E R OR OWNER
Ile He 7�5
r�
DATE PERMIT ISSUED �1
D A T E COMPLIANCE ISSUED
I
15
ISOis y.Z
M
- ASSESSORS MAP N0: �._�.
THE COMMONW Ir—M.4.55A�GH-USETTS
BOARD OF HEA T,�
.............. .......0F.............. L/G ......................
Appliratiun for Diuvu,iai Morku Tomitrur#inn Vamit
Application is hereby made for a Permit to Construct (� ) or Repair ( ) an Individual Sewage Disposal
System at:
.. ...........�_Lo 7_11 - _ -- ..... ... ......................
ocationA/ddoess � /�� or Lot�No.--
.. .......... ... >. •--------------------------------- ----- .....6.�./�...... .............. -
......
..---- : .:.
Ow r dress.
i
.. ......---- c= .....16a ............. ......... ---•------------------------- ..�.........
Installer U Address r -
0` ...60
Type of Building Size Lot..-. ,___.._ Sq. feet
V �...................Ex Expansion Attic Garba e Grinder,..., Dwelling—No. of Bedrooms.......................:. p ( ) g (.�
aOther—Type of Building ............................ No. of persons..........--.........-----.. Showers ( ) — Cafeteria ( )
114 Other fixtures ---------------•------•-----•---- .
f� --------
--------------
W Design Flow............................................gallons per person per day. Total daily flow................._.._.......gallons.
WSeptic Tank—Liquid capacity-.(..gallons Length................ Width................ Diameter.-.-.--.-.-----. Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( l
a Percolation Test Results Performed by �nG �........ (-u ..... Date w z (ple
-
,� Test Pit No. I A`........minutes per inch Depth of Test Pit.................... Depth to ground water....................---.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........---.............
�+ -----------------------------
--•-------------------------------.-.--------------------------------•----....-----
•.................
.........
-------------------
0 Description of Soil..................................................... . n�
................................................ ----------------------------------------------------•--• -------------- ------•---••--•------------•••--•--•--........--•---------------------------.
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------•-------------------------------------------......------.....----•-------------------------------------.....---...---------------...----------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5" f the State Sanitary Code— The undersigned further agrees not to place the system in
oper 'on until a Certificate of Compliance has been issue by f 4( th. �
tigned.............. ------------- --.------------. .... ------------ �Q Z--- --------..
Application Approved By............................................... ... �at �o
Da t
Application Disapproved for the following reasons:. ..--------•--••-------------------••-•---•---•----••--...-------------•--•---------...........--.....--..
-----------------------------------------•-----------------------------------------....-----•--------••------------------------------------------------•-••---------------••---•----------------...-----
Date
PermitNo......................................................... Issued_.......................................................
Date
7`7 O 1 3 , F$s�z�... �`'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H EALT
..............7 -....OF............. ..r ...
Appliratinn for Disposal Works Tonstrurtion Vrrntit
Application is hereby made for a Permit to Construct e( ) or Repair ( ) an Individual Sewage Disposal
System at: / Ify •- �-
;,5174 /' I 'J�L
\ ocation A�d ress !�- or LotAddre
No. �r��
.... .....
/ Installer i? •• --'--•-
Addre
d Type of Building Size Lot.__._. /'��� Sq. feet _
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
Other—Type of Building No. of ersons____________________________ Showers
a YP g ---------------•------------ P ( ) — Cafeteria ( )
Otherfixtures ..............................................•--- _.._.....-•----------.....•-----------••----•------•••••••••-
W Design Flow............................................gallons per person per day. Total daily flow................... ............gallons.
WSeptic Tank—Liquid capacity.jf0f_gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length Total leaching area...................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) // �, 1
Percolation Test Results Performed b ._ Y _ � ��!.....__ Date..... /�� �`
a y .... ,s9 - -- ----------�• ----------
a Test Pit No. 1___:+_:_ _.__minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --••-------------------•-•-------•-••-••-•.....-•-•.............-•••---•...••�-----._.......--•-----.......---•--..........._...._.............--......--•--
vO Description of Soil.....---•--------------------------- �' ---._.--._...=y-----•--------------.._. ....----------
••---------------------------------------------------- --- - '' _`' � - ,tM - - -
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U Nature of Repairs or Alterations—Answer when applicable.................................................................................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 f the State Sanitary Code—.The undersigned further agrees Inot to place the system in
opera on until a Certificate f Compliance has been issued by th boatd f hea
....... ...........l �
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............
ApplicationApproved By----------------------------------------------- =-----•......••••...._.... .............. --------- .............
Date
Application Disapproved for the following reasons_________________________________________________________________________________________________________.--
•••.....••••--•-----••--•-....__.....••••••-----•----•--••••••....--••--•--•-----...----•••••--•---•-••__.-••-•••-•-•--••--•••.._....----••-••--••-••......................................•-•-....---•-
Date
PermitNo...................................................--- IssuecL....................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_,/
........................•.................O F.......!.....................:....a.:..:............... ...........................
Trrtif utttp of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ") 'f or Repaired ( )
-- -Installer •• f-• :�� ...
at. ...............` 1r .: �r �-�Z ••------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code des ribed in the
application for Disposal Works Construction Permit No....... __'�.............. dated........ !��Q-c............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... 2.1.5 ...._.........-- Inspector _...._.........---------------•....._.__......_..............
" A 31 c, THE COMMONWEALTH OF MASSACHUSETTS
BOARD` OF ,HEALTH
_ � �' -''...OF...............1.. �'t. !j '".:-�._�......... po
No... C�.....:. . o Fay..:. S..:::..
14opoottl Works Tono#.ration ramit
Permission is hereby granted... ...`_.,A_M j.....-••- .................... ...............
to Construct or Repair ( ) an Individual Sewage Disp System sn ----•••-
at No.................................... _O_:..:..............._._-_EL!_►-�.k....[-- -- Vic-tJ'' 1�' 1 r ��
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Stree
as shown on the application for Disposal Works Construction Permit tNo... �?: ?. Dated............7 �1G
__ ........
_ ...........................-.............. .... .... Cr..............------........_...._
/ ' C Roar of Health
DATE.. --•------------------------...------••-___•-•--•••........ t
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LEVY & ELDREDGE ASSOCIATES, INC .
CL:IEN.T'�N�CKvc.Pt i CERTIFY THAT THE PROPOSED
ENGINEERS-LANDSCAPE ARCHITECTS I'
L PLANNERS JOB NO. 5a BU.I.L0jNG .'SHOWN ON THIS ,PLAN
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OF BARNSTABLE `MASS.
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N
240:31' BENCHMARK BOULDER BOUND MROAD
ELEVATION 119.11 6LOCUS
ISLANDLL- 6k I -. I I I i s \ I \ \ \
^ .4 ) LOCUS MAP
13$ / NOT TO SCALE:
0 30 45 60
GRAPHIC SCALE: / \ \ \ I I I l\'::; :;:\ �� \ \ .� L- \ V`
1 INCH = 30 FEET , \ \ \ \ \ ; \ \ \ ROd'
T.T.H. #2\
2011-0128-SEP.DWG 13� LIMITS OF \ \\ \ \ \� ; \
EXCAVATION \ \ \ \ '\ \\ :. •;•: :1 �N
SEWAGE TO C-2 LAYER \ \ \ \�\ \ \
SITE 8c Qo \ \\ \ \\ \ D.T.Ik #� \ �� ,\
REPAIR PLAN \ \ \ \� �,, \
Q \ \ \ �� f`
j2J5 :10 _ \ V
BOULDER ROAD ° ED A OL
�RD
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I N ; � STONE :
BARNSTA f p S
DATE: DECEMBER 15," 201T
OWNER/APPLICANT: I I I PUMP, CRUSH & ##235
_
PATRICIA A. CARBONE' ABANDON OLD S.A.S. DECK \� N
235 BOULDER ROAD IN ACCORDANCE WITH I I I 1 1 . 11
TITLE 5 I \
BARNSTABLE
GARAGE
LOCUS DATA
MA
MASSACHUSETTS ► \ \ q
. . \ �i / / // ./ // ce,
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CURRENT OWNER PATRICIA CARBONS \ \ \ / / / p� �9S
SHEET 1 OF 2
PLAN REFERENCE 409-89 SHE
PREPARED
PREPARED BY: DEED REFERENCE 12651-294
E A S SURVEY, I N C. BENCHMARK
}, ZONING DISTRICT RF-1 BULKHEAD CORNER // // /,�' DATUM :
141 R T. 6 A ELEVATION 129.78
OVERLAY DIST. NOT A ZONE it /
P . O. BOX 1729 � VERTICAL DATUM: BARNSTABLE GIS. MSLf
ASSESSORS MAP 315 BENCH MARK USED: CORNER BULKHEAD
s SANDWICH,' MA 02563 PARCEL 036 ELEVATION 129.78
PH. (508) 888-3619
LOT AREA 43,996t S.F. "
CELL (508) 527-3600
SYSTEM DESIGN
RAISE COVERS TO WITHIN 8" OF FINISH GRADE
DESIGN FLOW
SILL = 130.50 3 BEDROOMS AT.110 GPB/D 3M GPD
F.G. ELEV. 129.7 FG 129.6 FG 29.2 FG 126.5
//�\\ \ /�Z\\ - \\ \ I FG 12.7.0 FG 126.0 REQUIRED SEPTIC TANK
TOP1212
36" MAX. COVER OBS. ��� ___330 x_2 _ __ 660 GAL.
4„ 45'CS= 0.043 1®3' S=0.02 TOP ELEV 124.0 PORT(s) SEPTIC TANK PROVIDED = _1000 -GAL.
SCH 40 INV=PVC 4" PVC SCH 40 2�' S=0.01 L. ELEV=
15' FG 124.5SIZE OF LEACHING FACILITY REQUIRED
2 MIN-3 MAXINV= XISTING 126.05 10"TEE 14"TEE INV.=
` 125.85TRIPOUT ALL DESIGN PERC RATE __<2 ___MIN./INCH
GAS BAFFLE i 3 OUTLET UND TO C-2 LONG TERM APPL. RATE-4_74_GPD/S.F.
ID LEVEL D-BOX SET "QUIK-4" STANDARD LEVEL IZON. PER
CMR 15.255SIZE OF LEACHING SYSTEM PROVIDED:
INV.= 123.67 USE (24) QUIK 4 STANDARD 330 = 0.74 SF/GPD = _446 S.F. MIN. REQ.
00 o I o INV.=123.90 CHAMBERS TOTALING 96 LINEAR FEET 123.0
, INV.= 123.73 48"x34"x12" STONELESS BED FORMATION in
EXISTING 1,000 GAL TANK TO REMAIN T( _ � � TEST PIT # 1 ELEV 112.0 USING 24 STONELESS UNITS
( THREE ROW OF EIGHT PANELS ) 'INFILTRATOR - 24 QUIK "4" STANDARD
ADJ. HIGH GROUNDWATER
STRIPOUT 18.5' x 42.0' C•-"""'" ''- 4.73SF / LF X (3 x 32) ,454.08 S.F
I CERTIFY THAT I AM CURRENTLY APPROVED BY THE OBSERVATION PORT 454.08 x 0.74 G/SF = 336 GPD
DEPARTMENT OF ENVIRONMENTAL PROTECTION TO CONDUCT / SCREW CAP
2011-0128-SEP.DWG SOIL EVALUATIONS AND THAT THE RESULTS OF MY SOIL 336 GPD PROV > 330 GPD REQ. = 6 GPD RES.
EVALUATION ARE ACCURATE AND IN ACCORDANCE WITH 310
SITE 8c SEWAGE CMR 15.100 OU H 1 .1 SAND FILL MIN. . 6" ABOVE UNITS NO (GARBAGE DISPOSAL / GRINDER ALLOWED)
REPAIR PLAN EDWAR STONE, CERTIFIED SOIL EVALUATOR E
9J5 P#13487
GENERAL NOTES: --2.83'-------2.83'-- 2.83'--�
BOULDER ROAD TITLE TITLE OVRANDNTHEALL WKMASHIPTOWN OF BARNSTABLEAND MATERIALS L RULES OAND REGULATIONS5' 8.5' �r DATE: 12-8-1111 DATE: 12 8-1111
N FOR SUBSURFACE DISPOSAL OF SEWERAGE. END VIEW GROUND ELEV. 126.4 GROUND ELEV. 125.0
2. AT LEAST ONE ACCESS POINT OVER TANK TEES SHALL BE NO GROUNDWATER NO GROUNDWATER
B A R N S TA B L E, MA ACCESSIBLE WITHIN 6" OF FINISH GRADE, WITH ANY REMAINING
ACCESS PORTS BROUGHT TO WITHIN 6" OF FINISH GRADE. CONSTRUCTION NOTES:
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE
DATE: DECEMBER 15, 2011 LOAMY SAND LOAMY s ND
CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND 10YR 4/3 10YR 4/3
OWNER/APPLICANT: UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEY ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING 10YR 5/1 10YR 5/1
MUST WITHSTAND H-20 LOADING. WORK ON THE SITE. 16" 12"
PATRICIA A. C A R B 0 N E 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION 2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE B B
OF ALL UTILITIES PRIOR TO ANY EXCAVATION. WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT LOAMY SAND LOAMY SAND
2,35 BOULDER ROAD 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE 7.5YR 5 6 42„ 7.5YR 5 6 1 36"
OR WITHIN 6 OF GRADE SHALL BE MORTARED IN PLACE. Cd-1 Cd-1
B A R N S TA B LE 6. FINISH GRADE SHALL HAVE A MINIMUM OF 0.02 FEET PER AUTHORITY.
3. VEHICULAR TRAFFIC, PARKING OF VEHICLES AND PLACING SILT LOAM,. SILT LOAM
FOOT OVER THE S.A.S. AND DISTRIBUTION BOX. MATERIALS OVER THE SEPTIC TANK, DISTRIBUTION BOX;AND 10Yr 6 6 •96' 10YR 6 6 90„
M A S S A C H U S E TTS 7. SEPTIC TANK SANITARY TEE'S SHALL BE CONSTRUCTED OF S.A.S. AREA IS PROHIBITED ELEV =118.4 ELEV =117.5
SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6' ABOVE 4. CONTRACTOR TO CONFIRM INLET AND OUTLET "TEES" ON
MA THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND SEPTIC TANK AND INSTALL / REPLACE WHERE NECESSARY. C-2 C-2
LOCATED DIRECTLY UNDER THE CLEAN OUT MANHOLES. MEDIUM MEDIUM
SHEET 2 OF 2 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN SAND 108" SAND
2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT INDICATES 2.5Y 7/6 2.5Y 7/6
ELEVATION OF THE OUTLET PIPE. DTH #1 DEEP TEST NO G. WATER NO G. WATER
PREPARED BY: 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES HOLE 162" 156"
10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS, ELEV =112.9 ELEV =112.0
E A S SURVEY, INC. BAFFLE, 4 INCHES IN DIAMETER AND CONSTRUCTED OF 4" PVC T B.O.H.
11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND k "OF* DON DESMARAIS
141 R T. 6 A SHALL BE SLOPED 1/4 INCH PER FOOT MIN. EXCEPT FOR THE NONE ��� S9� INDICATES SOIL EVALUATOR
FIRST TWO FEET OUT OF THE DISTRIBUTION BOX WHICH SHALL o D ID ti P-1 108" SIEVE TEST ED. STONE
P. O. B 0 X 1729 BE LEVEL �� DOWN CAPE ENG. SOIL EV. LIC. APRIL, 1995
12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION LAH BACKHOE OPERATOR.
SANDWICH M A 0 2 5 6 3 TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW 21 NO MOTTLING RODNEY FISHER
AND APPROVAL.
� 'f p NO WEEPING SOIL TYPE: �_
PH. (508) 888-3619 13. MAGNETIC TAPE OVER ALL COMPONENTS. ! `�c/STE\ PERC RATE: <2 MIN. PER INCH
CELL (508) 527-3600 S�NITAR\P� LOADING RATE: 0_74 GAL/SF/MIN
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