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Home My WebLink About0045 COBBLE STONE ROAD - Health 45 Cobblestone Road Bamstabte A= 316-049-001 I. Commonwealth of Massachusetts IF Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =' 45 Cobblestone Rd Property Address Owner Sullivan ? information is Owner's Name / r ✓ t� Y required for Barnstable Ma 9-17-19 U every page. City/Town State Zip Code Date of Inspection C5 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: A. Inspector Information c5 When filling out P NA93 forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address Centerville Ma 02632 City/Town State Zip Code 508-420-4534 S14297 'efO" 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 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails i 9-17-19 t r' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts 6? Title 5 Official Inspection Form �~ �� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every 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: ® 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: At time of inspection this system met or exceeded all minimum passing requirements. This report can not predict the future performance under the same or increased usage. This report is not to be used for definitave bedroom count determination. House was built in 1999. Current owner has owned since 2011 1 am not sure if system is original or not. Only occupied by 2 people since 2011. 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 System•Page 2 of 18 Commonwealth of Massachusetts �. 19 Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. City/Town 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 1❑ 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts lF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityfrown 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 Commonwealth of Massachusetts �n ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every 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 a//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 I Commonwealth of Massachusetts �v ►F Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: According to as-built card this system consists of a septic tank d-box and 3 500 gallon chambers with 4 ft of stone. Number of current residents: 2 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 Seasonaluse? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage na at time of insp 9 ( Y 9 (gpd))� Detail: system NOT designed for usage with garbage disposal. Sump pump? ❑ Yes ❑ No Last date of occupancy: currently occupied t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n I� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityrrown 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: Owner stated pumping in July of 2018 By Lebouf septic Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 r Commonwealth of Massachusetts ?: Title 5 Official Inspection Form (/ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' / 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I r Commonwealth of Massachusetts Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � / 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) . 6. Septic Tank(locate on site plan): Depth below grade: 1.75 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: 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.): Tank was functioning properly at time of inspection. Owner stated pumping in July of 2018 by Lebouf septic t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 f Commonwealth of Massachusetts 1p Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityrrown 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 ❑ 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 ❑ polyethylene ❑ 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 Commonwealth of Massachusetts �. 1�? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every 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 o 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.): At time of inspection the d-box was functioning as it should, passing was based on findings in d-box t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r Commonwealth of Massachusetts �n 1p Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityrrown 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.): * 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: Depth (no risers found ) and ground was extremely hard at time of inspection so exact level of ponding was not determined. Passing was based on d-box findings. Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. City/Town State Zip Code Date of Inspection 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.): No risers were found close to grade and the ground was extremely hard so the s.a.s was not opened. there were no clear signs of failure in the area of sas at time of inspection. 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, level 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 r Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments >r 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityrrown 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts lig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityrrown 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 r Commonwealth of Massachusetts �. lig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4' 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityrrown 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: greater than 5feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: previous passing insp report. 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 ig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� 45 Cobblestone Rd Property Address Owner Sullivan information is Owner's Name required for Barnstable Ma 9-17-19 every page. Cityrrown 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Assessing As-Built Cards Page 1 of 2 Commonwealth of Massachusetts f ' # Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 45 Cobblestone Road Property Address Janet Derby Owner Owner's Name information is Barnstable MA 02630 August 28,2008 required for every 9 page. City/rown State Zip Code Date of Inspection D. System Information (cont.j' Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all welts within 100 feet. 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Pkel minai�r plans .b;layo tg yy'i♦u"p,t k ror file y}fc oJ�ttk}'cystomEls OnY/�oY t ie 13 rtticily P7ehit(1 The Commonwealth of Massachusetts Department of Industrial Accidents Offtce of Investigations 600 Washington Street - Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r Please.Print Lezibly Name(Business/Organization/Individual) a'P:r b Address: o S4-o-tc- . 'u City/State/Zip: h o2 3a Phone. SD a-_low'�� Are you an employer? Check the appropriate box: e of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I employees(full and/or part-time,).* hav&hired the sub-contractors" New construction .2.0 I am a sole proprietor or partner- listed on the attached sheet. J.[7T. D Remodeling , ship and have no employees '.These sub-contractors have Demolition workingfor me in an capacity. employees and have workers' Y P tY• $ ❑Building.addition [No workers'comp. insurance comp.insurance. Electrical re airs oradditions required.] 5. 0 We area corporation and its ❑ P3.K I am a homeowner doing all.work officers have exercised their 0 Plumb mi g repairs or additions myself. [No workers' comp. right of exemption per'MGL l2.0'R6of repairs insurance required.] t c."152, §.1(4),and we have Ao ' employees. [No workers'-. 13. Other comp.insurance required.] *Any applicant_that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. XContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a.copy of the workers'compensation policy declaration page(showing the policy number andexpiration date): t . Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties,in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certi nder he ains and enalties of perjury that the information provided.above is true and correct Signafore: Date: l Phone Official use only. Do not write in this area,to be completed by city or town official .City or Town: Permit/License# ' Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - Information and Instructions Massachusetts General Laws chapter 152'requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in,the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation-or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant,of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance.with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),.address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in__(city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call: The Department's address, telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4.900 ext 406 or 1-877-MASSAFE a Fax#617-727-774.9 Revised 11-22-06 www.mass.gov/dia �ofYr Town of Barnstable " Regulatory Services H� O R ARNn,BE Thomas F. Geiler, Director muss. 165q. 16. Building Division reo Ma's Tom Perry,Building Commissioner t� 200 Mairi.Street, Hyannis,Me A_02601 wTm.town.b arnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: "11 W 13 Kct ^—number �f str`cct ? p village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellin>?s of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFT MON OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a.one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constrgcts more than one home in a two-year period shall not be considered a bomeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that be/shc shall be responsible for all such work Performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minim inspecti rocedures and requirements and that he/she will comply with said procedures and re ernnts Signatur f Homeowner J Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION .The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section,(Sccrion 109.1.1.-Licensing of construction Supervisors);provided that if the homeowner engages a pm-son(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exerrrption arc unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homcowncr acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilitics,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a forra✓ccr ification for use in your community. Q:forms:homccxcmpt A^ '3 c G Commonwealth of Massachu "Ats Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assess ents z . 45 Cobblestone Road, Barnstable J ray,, Property Address -- r Janet Derby � _ � '� �z.. t .� V $i Owner Owners Name information is required for eve Barnstable MA 02630 October 6 every _ 2010 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 filling out forms A. General Information on the computer, use only the tab key to move your. 1. Inspector: O P cursor-do not Troy Williams use the return Name of Inspector key. _TroyWilliams Septic Inspections reb Company Name — --- -- . 19 Hummel Drive Company Address South Dennis MA __ 02660 City/Town State Zip Code 508 385-1300 _ S 1682 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 October 6, 2010 Inspector's Signature f — Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional.office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection�orrtl.Subsurface ge Dlsposel Syste rape 1 of 17 • a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner Owner's Name - — information is Barnstable MA 02630 October 6, 2010 required for every _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 or components, or the future structural integrity of system components and'represents conditions found on the day 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 sou nd, 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): N/A F t5lns•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner — — — -- Owner's Name information is Barnstable required for every MA 02630 October 6, 2010 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout 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): NIA ❑ 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): N/A C) further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,. safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner Owner's Name information is required for every Barnstable MA 02630 October 6, 2010 page. CitylTown. State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of.Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil.absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. . ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply, ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: _ `* This system passes if the well water analysis, performed at.a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A .D) System Failure Criteria Applicable to All Systems: You must indicate".Yes" or"No"to each of the following for all inspections: Yes No MBackup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool El ® 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 El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 1= Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 45 Cobblestone Road, Barnstable _ Property Address Janet Derby Owner Owner's Name information is required for every Barnstable MA 02630 October 6, 2010 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: N/A. ❑ ® Any portion of the SAS, cesspool or privy is below high groundwater 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 E] the system is located in a nitrogen sensitive area (Interim Wellhead Protection El 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=�carjt threat, or answered"yes" in Section D above the large system has failed. The owner or oany large system considered a significant threat under Section E or failed under Section D shall upgrade'the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 5 of 17 6, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Road, Barnstable Property Address Janet Derby. Owner Owner's Narne information is Barnstable MA 02630 -October 6 2010 required for every _ , page. City/town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in.the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? - ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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): 4 -- Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(forexample: 110 gpd x#of bedrooms): 440 gpd i t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 E, I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yr 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner Owner's Name information is required wired for every Barnstable _ MA 02630 October 6, 2010 page. City/Town State ZipCode Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 09=49,000 gals. Detail: 08=48,000 gals. Sump pump? El Yes ® No Last date of occupancy: occupied. Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 1.5.203): 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? ❑ 1(es ❑ 1No Non-sanitaryg y ;k waste discharged to the Title 5 system? ❑ es � o NIA # �i °# Water meter readings, if available: a`r t I l5ms"09108 a. Tide 5 Official Inspection Form Su j syrfece Sewayge�Dla I Syste,t a e 7 a - r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner Owner's Name information is Barnstable MA 02630 October 6 2010 required for every r page. City/Town State Zip Code Date of Inspection D. System Information, (cont.) Last date of occupancy/use: N/A Date Other(describe below): NIA General Information Pumping Records: Source of information: Last pumped on 0/9/06 per info from BOH. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A _ Reason for pumping: N/A Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow.cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology: Attach a copy of the.current operation and maintenance contract.(to be obtained from system owner).and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval, . ❑ Other(describe): t5ins•09l09 Title 5 Official Inspection Form:Subsurface_Sewage Disposal Sys!;nl Peg;B gf t7 w . Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 45 Cobblestone Road, Barnstable Property Address Janet Derby _ Owner Owner's Name information is required for everyBarnstable MA 02630 October 6, 2010 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: Tank, d-box& leaching were installed on 1/25/99 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No t Building Sewer(locate on site plan): Depth below grade: 18"+ feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.)-. Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'X 10.5'X 6' 1500 gallon 4'! Sludge depth: °YR t5ins•08/08. Title 5 Official inspection Form:Subsurface Sewage plsposal System �a e 9 or Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System(Form - Not for Voluntary Assessments 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner Owner's Name information is Barnstable MA 02630 October 6 2010 required for every _ , page. City/Town State Zip Code Date of Inspection D. System Information (cont) e Sp tic Tank cont. Distance from top of sludge to bottom of outlet tee or baffle 2.' 8 Scum thickness none Distance from top of scum to top of outlet tee or baffle 6'' Distance from bottom of scum to bottom of outlet tee or baffle 14 Probe/measured 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.): Pvc inlet and outlet tees were present. No evidence of leakage or damage was found at the time of inspection. 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: El 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 E t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Pape 10 of 17 3 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner Owner's Name information is required for every Barnstable MA 02630 October 6.2010 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.): N/A 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 ❑ o.. � �Jr a. t5ins-09108 Title 5 Official Inspection Forth Subsurface Sewage Disposal System Page 11 of 17 x y 77 t '� 1y ft OL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 45 Cobblestone_Road, Barnstable Property Address ---------_--- --_ -�- Janet Derby_ Owner Owner's Name information is required for every Barnstable MA 02630 October 6, 2010. _ _ 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 with 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. 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 Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A t5ins-09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Cobblestone _Road Barnstable_ Property Address Janet Derby _ Owner Owner's Name required for is y Barnstable required for ever MA 02630 October 6, 2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits, number: ® -leaching chambers number: 3 500 gal. chambers ❑ leaching galleries number. with 4' of stone ❑ 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.): Soil was sandy. Chambers were found with very little water present with a visible stain line approx. 4" from the bottom. Checked stone and found dry and clean. No evidence of hydraulic failure or, Problems in the past 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 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 fi f r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'" 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner Owner's Name information is required for every Barnstable MA 02630 October 6, 2010 _. page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 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 so il, signs of hydraulic failure( g , level of ponding, condition of vegetation, etc.): NIA t5ins•09/08 TWO 5 Official Inspection Form:Subsurface$ewaQa Dlspogal Systerq Pepe 14 of 17 s Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Road, Barnstable Property Address Janet Derby_______ Owner Owner's Name information is Barnstable _ required for every MA 02630 October 6, 2010 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 I n1'Gh` . I O fj 3 3 ' B 1 ly'gl' i '1-r- 2 2u 2 3 Sot Y " 3r t5ins•09l08 Title 5 Official inspection Form:Subsurface Sewage Disposal system t Page 15 of . . ,fir ri p � `�q a'� <•fy,�k, t, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 wM y 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner Owner's Name information is required for every Barnstable MA 02630 October 6, 2010 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: 30+' 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: 10/22/98 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) J Accessed USGS database-explain: AIW 247 Zone C 22.9' 2.9 adjustment You must describe how you established the high ground water elevation: Hand augered 6' below bottom of leaching with no water found at 10.0'. Groundwater adjustment at the time of inspection was 2.9'. Bottom of leaching at 4.0' was found not to be located in the high roundwater level at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page, i t5ins•08/08 Title 5 Official Inspection Form;Subsurface Sewage Dis P 8 posal system•Page J 6 of 17 fit. I Commonwealth of Massachusetts ' . Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Cobblestone Road, Barnstable Property Address Janet Derby Owner Owner's Name information is Barnstable _ MA 02630 October 6, 2010 required for every _ page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 6 t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f �L, Commonwealth of Massachusetts P- y y Od Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Cobblestone.Road ,-%e>aA vL iQ� . Property Address Janet Derby Owner Owner's Name information is , Barnstable MA' 02630 August 28 2008 required for every' 9 , page. Cityrrown 'State Zip Code Date of Inspection Inspection results must be submitted on this form'. Inspection forms may`not be altered-in any way. Important:When filling out forms A. General Information on the computer, ED .U use only the tab 1. Inspector: key to move your S I, cursor-do not Troy Williams use the return key. Name of Inspector Troy Williams Septic Inspections reb Company Name 19 Hummel Drive Company Address South Dennis MA 02660 City/Town 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 1.5:340rof' Title 5(310 CMR 15.000).The system: ® Passes C � ❑ Conditionally Passes ❑' Falls ElNeeds Further Evaluation by the Local Approving Authority 4 August 28; 2008 . Inspector's Signature, Date The system.inspector shall submit a copy of this inspection report to the Approving.A ahority(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 DER 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 inspectiorf'does not address how the system will perform in the future under the same or different conditions of use. , l '�D 45 Cobblestone Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 4 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Cobblestone Road Property Address Janet Derby Owner Owner's Name information is bl tae required for every Barns MA 02630 August 28, 2008 page., Cityrrown _ State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ,. ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15-303 or'in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ 'One or more system components.as described in the"Conditional Pass"section need to be replaced,or repaired. The system, upon completion of the replacement or repair, as approved by' the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. El 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, not1eaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: N/A ❑ Observation of sewage backup or break or high static wate(.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 replaced7. : El obstruction'is removed' 45 Cobblestone Road,Barnstable 03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Cobblestone Road Property Address Janet Derby Owner Owner's Name information is Barnstable MA 02630 August 28, 2008 required for every 9 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ distribution box is-leveled or replaced ND Explain: N/A ❑ The system, required pumping more than 4 times a'year due to broken or obstructed pipe'(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: N/A C) Further Evaluation-is.Required by,the Board of Health: ❑ Conditions exist which require further evaluation by.the Board of Health in order to determine if the system is failing to protect public health, safety or the environment: 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner.which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering.vegetated wetland or a salt marsh 2. System will fail unless the Board of Heal'th.(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. 45 Cobblestone Road,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 } Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Cobblestone Road Property Address Janet Derby Owner Owner's Name information is Barnstable MA 02630 August 28, 2008 required for every 9 page. City/Town State Zip Code Date.of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well". Method used to determine distance: N/A '*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the an must be attached to this form. 3. Other: N/A D) System Failure Criteria Applicable to AII'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 cloggedcesspool SAS or I . P Q ® 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 '/z day flow ❑ ® Required pumping more than 4 times in the'last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: El ® 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. 45 Cobblestone Road,Barnstable 03/08 Title 5 Official Inspection Form-Subsurface Sewage Disposal System.Page 4 of 15 t fs .bt;,, ty,• E. Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,..'' 45 Cobblestone Road Property Address Janet Derby_ Owner . Owner's Name information is Barnstable MA 02630 August 28, 2008 required for every g page, Cityrrown State Zip Code Date of Inspection B. Certification (coot.) D) System failure Criteria Applicable to AII:Systems:(cont.): Yes No. ❑- ® Any portion of a cesspool or-privy.is within a Zone 1 of a public well. ❑ ® Any portion of a,cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than.100 feet but greater than 50 feet from,a private water supply well with no acceptable water quality analysis. [This system passes.if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence: of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form..] I ❑ ® ' 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._ v 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. 45 Cobblestone Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth•of Massachusetts Title 5 Official Inspection Forms _ Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 45 Cobblestone Road Property Address Janet Derby Owner Owner's Name information is Barnstable MA _026_30 August 28, 2008`.required for every _ 9 page.' City/Town State Zip Code Date of inspection C. Checklist Check if the following have been done.You must indicate"yes",or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® El- Has the system received normal flows in the previous two week period? El ® 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 El 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 El information on the proper maintenance of subsurface sewage disposal systems? i 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)] 45 Cobblestone Road,Barnstable•03f08 Title 5 Official Inspection Form:Subsurface sewage bisposal System•Paga 6 of 15 ' t- f Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 45 Cobblestone Road Property Address Janet Derby Owner Owner's Name information is Barnstable MA 02630 Au ust 28, 2008 required,for every 9 page. CityrFown State Zip Code Date of Inspection D. System Information Residential Flow,Conditions: Number of bedrooms (design): 4 Numbe ooms actual :r of bedr 4 ' DESIGN flow based on 310.CMR.15.203 (for example: 110 gpd x#of bedrooms): ' 440 gpd Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ®'No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes M No Laundry system inspected?.. :.® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings,,if available last 2 ears usage (gpd)):. 07=48,000gals 9 ( y 9. (gP.))= 06=49,000gals Sump pump? ❑ Yes M No Last date of occupancy: ; _ Occupied Date Commercialllndustrial Flow Conditions: Type of Establishment: N/A N/A Design flow(based on 310 CMR 15.203): , . 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 Last date of occupancy/use: N/A Date Other(describe): N/A 45 Cobblestone Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Cobblestone Road �r Property Address Janet Derby Owner Owner's Name information is Barnstable MA 02630 August 28 2008 required for eve 9 4 every page. Cityfrown State Zip Code Date of Inspection D. System.Information cont. y . c ) General Information' Pumping Records:. Source of information: Pumped on 8/9/06 per BOH. Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: N/A gallons How was quantity pumped determined? NIA Reason for pumping; . N/A Type of System ® Septic tank,distribution`box, soil absorption'system; ❑ Single cesspool. ❑ Overflow cesspool El 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: Tank, d-box& leaching were installed on 1/25/99 per compliance. Were sewage odors detected when arrlving.at the.siteT ❑ Yes M No 45 Cobblestone Road,Barnstable•03108 ,Title 5 Official Inspection form Subsurface Sewage Disposal System Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments,`- M y` 45 Cobblestone Road Property Address Janet Derby _ Owner Owner's Name information is Barnstable MA 02630 August 28, 2008 required for every 9 page. Cityfrown State Zip Code. Date of Inspection D. System Information (cont) Building Sewer(locate on site plan): i Depth below grade: 18"+ feet Material of construction: ❑ cast iron ® 40 PVC El other(explain): Distance from private water supply well or suction liner N/A feet Comments(ph condition of joints,venting evidence of leakage,-etc.): Flushed lines and found clear at the.time of inspection. Septic Tank(locate on site plan) 101. Depth below grade: feet Material of construction`. ®,concrete ❑ metal ❑fiberglass ❑polyethylene ❑.other(explain) If tank is metal, list age: N/A. years . Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6 X 10.6'X 6' 1500 gallon i Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 2'8,. Scum.thickness none 6 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14' How were dimensions determined? Probe/Measured ' 45 Cobblestone Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 i 1, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ; M y�� 45 Cobblestone Road Property Address . Janet Derby Owner Owner's Name information is Barnstable MA 02630 August 28, 2008 required for every 9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cony) Comments (on pumping recommendations' inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): Pvc inlet and outlet tee's were present. 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 1❑ fiberglass ❑ polyethylene ❑ other(explain): N/A 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,"evidence of leakage, etc.): N/A . Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): t Depth below.grade: N/A � P Material of construction: - ❑ concrete ❑ metal ❑"fiberglass ❑ polyethylene ❑ other(explain): N/A' 45 Cobblestone Road,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 f Commonwealth of Massachusetts = Title 5 Official Inspection Form_ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 45 Cobblestone Road - Property Address Janet Derby. Owner Owner's Name „w information is Barnstable MA." 002630 August 28,2008 required for every. _9 _ page. CityTrown State." Zip.Code - Date of Inspection D. ,System Information '(cont') Tight or Holding Tank(cont.)' , N/A Dimensions: Capacity: N/A' gallons. Design Flow: N/A , gallons per day Alarm present: ❑ =Yes' . ❑ No m , 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 k *Attach copy of current pumping contract(required).'Is copy attached? " ❑ Yes :.❑. No Distribution Box(if present must be opened) (locate on site plan):. Depth-of liquid level;above outlet invert Level with Comments(note if box is level and"distribution to outlets equal, an evidence of solids carryover„any evidence of leakage into or out of box, etc.). ,D-box was found level and in working order Pump Chamber(locate on'site plan): f f Pumps In worWng order. ❑ Yes- ❑ No ` L Alarms in working order: ❑ Yes ❑ No 45 Cobblestone Road,Barnstable 03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 15 t . . a t fa MO Commonwealth of Massachusetts ' Title 5 Official Inspedti0h Form Subsurface Sewage Disposal.System'Form -Not for Voluntary'Assessments.: M 45 Cobblestone Road Property Address ; Janet Derby Owner Owner's Name information ie Barnstable MA: 02630 Au ust 28, 2008 required for every g page. City/Town State Zip Code bate of Inspection D. System Information (cont.) fi Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): ° N/A Soil Absorption System(SAS) (locate on site plan, excavation not required) r. If SAS not located, explain why: N/A F Type: El leaching pits number: 3-500 gal: leaching chambers .. , number: chamb w%4'stone leaching galleries- •number: 0 leaching trenches number, length.. • [] leaching fields number, dimensions: E] overflow cesspool number: ❑ innovative/alternative systemP Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of Y vegetation, etc.): 'Chambers were.found with little water:presentpwith a visible stain line approx: 4"from bottom. No evidence of hydraulic failure or,problems in'the past,were found at the time of inspection: 45 Cobblestone Road,Barnstable 03/08 " Title 5.Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts = Title 5 Official Inspection. - Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 45 Cobblestone Road Property Address Janet Derby Owner Owners Name information is for every rewired Barnstable MA �02 630 Au gust ust 28 2008 4 page. Cityrrown State _ Zip Code'-' Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A N/A Depth top of liquid to inlet invert Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool M N/A Materials of construction N/A Indication of groundwater inflow ❑ .Yes ❑ No 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 Comments.(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.).- N/A i 45 Cobblestone Road,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 ... f°. Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary_Assessments M 45 Cobblestone Road Property Address - Janet Derby Owner Owners Name information is Barnstable MA 02630, August 28, 2008 required for every • 9 page. Cityrrown State Zip Code Date of Inspection --------------------- D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells'within100 feet. Locate where public water supply enters the building. �n1wf w t %.4"Y tl c-- - 33, 13 1 - ►� Z6' - - - - - - - - - i . F 1y 0 L - - - - - � 3 C� a, 4.0 L-D. - Y y,,w A. viGS 45 Cobblestone Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 1.5 t s t Commonwealth of Massachusetts Title 5 Official In o Inspection Form . p m Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments M •�''a 45 Cobblestone Road Property Address Janet Derby Owner Owner's Name information is Barnstable MA 02630 Au ust 28, 2008 required for every 9 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 groundwater. 30+ 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: 10/22/98 Date. ® Observed site (abutting property/observationx hole within 156 feet of SAS) ❑ Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Al W247 Zone C 23.9' 4.3' adjustment You must describe how you established the high'ground water elevation: Soil was sandy. Hand augered 6' below-bottom of leaching with no water found at 10.0'. Groundwater adjustment in area at the time of inspection was 4.3'. Bottom of leaching at 4,.0'was found not to be located in the.high groundwater elevation at the time of inspection.Groundwater map elevations showed groundwater to be approx:67.0' 45 Cobblestone Road,Barnstable•03108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF BARNSTABLE LOCATION A' &e-BE.iSTeasG 20 4b SEWAGE # y '10C w VILLAGE 1344".TrA6L6 ASSESSOR'S MAP & LOT S1 INSTALLER'S NAME&PHONE NO. 14-0 Lzi!_X_ 42-0 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) -3it Edo CkXMS MS (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: �'.L '`1 fi 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) 0 fJ C Feet Edge of Wetland and Leaching Facility(If any wetlands exist � within 300 feet of leaching facility) Feet Furnished by c4tr, A; 4-8 ' a 0-® a � � r No. 700 ___.�Rl Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes �c7 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,. MASSACHUSETTS 0(ppCication for Mi5pooal *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. L DT 79-A /L oT 1 Owner's Name,Address and Tel.No. 1 50$-�71-R?Z. V C088LEST014E 1QOA'D, SfARuSYfNSLE VILLAGE M.tM. W%t0AM R1CL1 Assessor's Map/Parcel 5S S M AP 31 F, I TC 49-1 V1 T y fl�M OV'T H t MA OZ673 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7. II k SroN ADVMICE10 TECkM lCkL sat�'i'�o>JS 3Au'SES a.13l'1 Ww WAY P.A,so)( S9 � E. SA1 0. � MA 0253-i 5,Ax1rJW 1e� MA o2563 1 -50%- 613$-4on Type of Building: Dwelling V No.of Bedrooms 4 Lot Size ?9�sq.ft. Garbage Grinder(two) • Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 411.-D gallons per day. Calculated daily flow gallons. Plan Date 1 0-Z7 5% Number of sheets 2 Revision Date Title SE WAGS. R15P0SAt SYSTEM DESIGN t SIT£ TQ" Size of Septic Tank Type of S.A.S. LEACH IN G C Okt-A >r rZ5 v 1 Description of So• O-G"L OAK 6a +S'� L oAMy smty 48��144 P4- C Sistjt)t G-Rkq - (� y_Gn LoArn 6,Lro LokM\1 SAN-0 G0"-I 4-4 Nl-C SR4pt GR\VEt-. Nature of Repairs or Alterations(Answer when applicable) 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 beeniss by this Board o ealth. _ Signed'V Date Application Approved by C Date -7 0- Application Disapproved for the following reasons Permit No. -7 0 0 Date Issued �� 0 .�%H y}�_ � ' t _ •. .. Q D� i., �� i�iii- i n ` f No. /o O .,•s r.- ...r...r�: Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. •V/ i a Yes I_c7 PUBLIC HEALTH"DIVISION - TOWN`OF BARNSTABLE., MASSACHUSETTS Z � f �( 0(pprication for MigaaY,�pgtem Construction Permit Application fora Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. LOT 7 9-n l L oT I Owner's Name,Address and Tel.No. I-570S-7 71 •2'( Col!,BLEST04E ROkD, 13A•RNSTAgLE VILLAGE: M•aM• W11_LIAM^ KICC1 1 4 Assessor's Map/Parcel '5 4-S C AMP S T R E E T M AP 316 , PC 49-1 VJ fST y ARM ov-f 1-1, MA 02673 Installer's Name,Address,and Tel.No. !;50$'FS4°j u Z 7Z Designer's Name,Address and Tel.No. 7. 1�oLL�t�� SD1J ADvNJCED TECHWICNL SbW IIO/�$ A� SEi3 AST► AN WAY P.D. BO)Y S9 I E. S>aw7- , MA 02531 , .SAiITWIC1\, I`AK o?563 I -5o3 g88-4-029 Type of Building: > `+ Dwelling v' No.of Bedrooms 4- Lot Size 79 1 G9 3 sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) t Other Fixtures I y al Design Flow `4`i'� gallons per day. Calculated daily flow lons.4 0 g Plan Date C-Z 7-516 Number of sheets Z Revision Date Title ' Sl WAGC- D1SPo5At SY5TEt\J\,Dt5.IGW' t SITC P�A� Size of Septic Tank Type of S.A.S. LEACHI N G C 0AM�1P_RS Description of SOit3) o-(o` L 0AM ; t6 g-$'� j OAMy SNNI 48'� )+'+ I`4- CSANDQ GRA,4 0-. ;;SAND G0"-144-4' sA1wD4' C-sRK\l \- Nature of Repairs or Alterations(Answer when_applicable) e Date last inspected: F r' Agreement: The undersigned agrees to ensure the construction and maintenance of the-afore described on-site sewage disposal system t ! in accordance with the provisions of Title 5 of the Env• onmental Code and not to place the system in operation until a Certifi - cate of Compliance hasbeen iss�'by his Board o ealth. ,.,-signedr Date 2-5 9 Application Approved by Date ft� 7 r qda_�_ Application Disapproved for the following reasons i r , Permit No. ` -7 D® . Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ff BARNSTABLE, MASSACHUSETTS Certificate of Compliance. THIS IS TO CER _ ,,that the On-site Sew a Disposal System Constructed( Repaired ( )Upgraded( ) Abandoned( )by � at 4 � Gb ,6-4&J has been constructed in accordance with the provisions of Title 5'and the for Disposal System Construction Permit No. 9 70 dated�/0 -3 0 Installer Designer The issuance of this permit shall not be ooj�stfu d as a guarantee that the system willtfunction as designeyd�fl c'' Date �'17 Inspector yHG- - -- .- ------ —————— ------ -- _. I Fee THE COMMONWEALTH OF MASSACHUSETTS" PUBLIC HEALTH-'DIVISION - BARNSTABLE., MASSACHUSETTS 1=i!5pogar 6ppotem Con5tructiott Permit Permission is hereby granted to Cos ct( air Upg de( )A andon( ) System located at �S___ zj �, 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 thi e it. f Date: //7 5/�� Approved by -� i/ w�a TOWN OF BARNSTABLE LOCATION '/S &861-i�S-Fosi 2C Ab - SEWAGE # VILLAGE C��rL,vSTAt3LE ASSESSOR'S MAP & LOT i INSTALLER'S NAME&PHONE NO. 2J i "'� f-�u`�� L`' — °Z S'D SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Sec ^fiC L1\R,vU3��25 (size) NO.OF BEDROOMS BUILDER OR OWNER -t cc t PERMITDATE: �' Z� ' 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 -J Feet on site or within 200 feet of leaching facility) � Edge of Wetland and Leaching Facility(If any wetlands exist �J 0`.; Feet within 300 feet of leaching facility) Furnished by Chit pLat,N 0 - OF I Z CD D-0� c a gi 9-�/ Jd _____---- 4 1 u�� ►► ul i��a► ►►5(�t►�►� 3-�� 3 _ V pepttrtment of Health,Safety,and Environmental Services ,< pate ' public ]Health Division d ms J67 Main Street,Ilyennis MA 02601 t &4pMreaJL I S 'TimeFee J � ^ZZ t61 Date Scheduled or Sewage Disposal , Soil Suitability Assessment.� Sc��.Y D11 N N SS O C Witnessed By: Performed By: L M riCATION & GENERAIJ O"cr,s 14wne LION I OM LOCO" y 1 own 3+5 CA.N� ' OZ(G73 Tj 31 (o � rn� Location Adds �' ' M SZ a W�" �� Address v4'P51- vr�� Vat L��c � Engineer•sName I-AN 1�'jl`1�ssa C. Assessor's Mepiparcel: �,,� 31 l I 1 �Z N C 4'q Telephone/ 4�ts �_ REPAIR Al,A- NEW CONSTRUCTION Z % Surncce Stones RE 5- p`rl>=L` ► N� slopes V/.) ater We11 Tj• tt Lend Use /�/,J\, tt prinking W �_- �,A- R Possible Wet Area B Distances from: Open Water Body -t, . Other W. A• a Property Line 2, —ft Drainage Way Of lot,exact locations of test holes dt Pe fats,locate Welland,inproximity to Ala) ' SKETCH:(Street name,dimensions 1 Tow 1 Wit R l ICE COrJTA+CT aUTV�Ir3H peptittoBedrock A �D>✓i— Parent material(geologic) od Weeping from Pit Pace Depth to Groundwater: Standing Water In Hole: Estimated Seasonal High around•"a!er ATION FOR SEASONA�•�O VAS' R TAUS ` ..,.... I)ETr JIMIN in. in. Depth tv son mottles: 4t• Mcthod Used: in Oroundwater Adjustment Depih Observed standing In obs.hole: Adj.factor�._Adj.OTOundweter Level Depth to weeping from side of obs.hole: Rending Date: index Well level,•,___— Index Well ff ..;.,,,:..<:•:::. PERCOLATION TEsT ; lflte Observation , Nola N 4 a lime at b"• — Depth of Perc Time(9"-6") Start Pre-soak Time® --- — End Pre-look Role Min./inch assed Site Felled: Additional Testing Needed(YIN) Site Suitability Assessment: Site P — Public health Division Observation Hole Data To Be Completed on Back Original. -� Copy: Applicant I IUN itUIT1 106 soil Utl,cr 61.5, ) oBsE,, sole'Ic.rlure Soil color Mottling ( - oll Structure,Stones,no„Idcn:f. oeplb from Soll I lorizon (USDA) (Munsell) Surface(in.) l oYR 4/3 FOAM (a= 1}c3 cAr10 2.�Y 7'3 49 —Ii`i C Hul soil color�;Cp 0iisr WA')t'1dN ktOL son nonlderef. Soil Texture So Mottling (Structure,Stones, U I)ep th from Soil I IN" (USDA) (Munsell) , Surface(in.) >~o�M i oyR 413 0-6 O/A L oAMY 7.5 rZ 5�6 S oM� . 60, ]3 SAN- // C /•�-C SNNQ 2 S"(-r(- C hhr►� Onsr,,RVA'�ldN 1iULCl OW:... son Stones,nouldera. Soil7exture Molllind (Structure, I)cplir from SoilIlorizon (uSUA) (Munsell) Surfnce(in.) 11n1c#,�..�.— llCC,I' OI3SL,,VA'I'ION ROL LOG soil otncr Soll Color l Mottling (Stnrctum.Stones,Douldcref. Son it IN" Soil'rexture (Munsell) I)cplh from (USDA) Surfnce(In.) r FJ�tllawr� �` / Above 500 year good boundary No Yes J_ within SOo year boundary No, Yes — within 100 year good boundary No_ Yes ervtous material exist III Nil areas observed throughout the Ily occurring Does at least proposed for the soil absorption system? Y�-- area prop - tfnot,what is the depth of naturally occurring pervious material? a LL 96 (dale)1 have passed the soil evaluator examination apptoved by the certify that on F�` ,,,,. • t,r � bove analysis was perform h performed by me consistent wit nvirontncnta) Protection and that the a -•rir.ncc described in I10 -MR 15.017. i Towh of.Sa rnstabte Department of Health,Safety,and Environmental Services Public Health Division Datr I U - -`Y 367 Main Strcct,Hyannis MA 02601 i I 6AIWlr1'AO{t MAti(1. so lj.M _.`rafia Date Scheduled OCT 1 5 l`�'l6 Time _ 00 — Fee Pd. t ' #.�... Soil Suitability Assessment or'Se►vage Disposal 11 w N Uec- PerformeeiBy- DANIEt_ /4 , C).\,A(-^ ENG\M• Witnessed By:-- J� :��T� VVN/�(/V�(BOI4) LOCATION & GENERAL INFORMATION Location Address LJO-T 1 6-15 Owner's Name �N""I\-,D NAnn'E;FMA'►i LAN M�cr1gC�.S CvMA^,A,Nv1D /1�tN5MLf-) dress -L� --rp��J Lr•I ' 6'L�Slro L- j�-Z. OZ�Soh Assessor's Map/Parcel: '"�1.�0` /�� Engineer*$Name a 3 N CIS j-� t►J. NEW CONSTRUCTION ✓'yRr•PAIR _ Telcphonc0 CiO,$ j6� ySyl Land Use _ �/� �Pt/"� Slopes(°•o) .."-O' Surlacc Stones- -r��w Distances from: Open Water Body ft Possible Wet Area ' ft Drinking Water Wcll ft Drainage Way ft Property Line *-Ar—'` it ether ft SKETCH:(street name,dimensions of lot,exact locations of test holes&pen;tests,locate wetlands to proximity to holes) � 45► � 33 �? �Tl1Z 3 rA y. . lroc�� ' S i 30 r 3�4 r Parent material(geologic) �0., �P`� �ln.��- Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face- Estimated Seasonal Nigh Groundwater /Ud GIiOV NI��AJf��Z" L t'®V N 1� DETERMINATION FOR SEASONAL HIGH WATER TABLE. A9ethuJ Uscd: Depth Observed standing in obs.hole: _ /4 in. Depth to soil mottles: in_ Depth to weeping from side of obs.hole, in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater bevel PERCOLATION TEST Date In/it; ]'imc_�� Y, x ..• a r,. ..' ,. Observation Z Hole N c; ^ Time a1.9�� .r -ten `�r a t Depth of Pere 1 ul_ 01 9 D 4a Time at 6" Start Prc-soakYTime L 0:00 01.00 Time(9"•6") End Prt-soak Lq r�)5 ou lH;70 Rate Min./Inch L'2' 2 Msr►�0� Site Suitabilily Assessment: Site Passcd- V/- Site Failed: — Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data T'o fie !,,d on Back- Copy: Applicant DEEP OBSERVATION HOLE LOG Hole #7N1 Depth from Soil Horizon Soil Texture Soil Color Soil Qthcr Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Bouldcres. Consisicncy 0 2-� C SL 2 _5- Ill 10` it b/►. t 'v' ' (I?- I.DAM` 1 L 6�4 - �� 5\, DEEP OBSERVATION HOLE LOG Hole#_�yZ Depth from Soil horizon Soil Texture Soil Color Soil other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Ov Gravel Orr'An' (_ I k 0\ja"5/l Z� t^ �.-S Z-S ` -7/1 LOAAJ 6AN 'L -5- L�4 Zo% t:o)+b tr.5, 6,- 10$ '�cI(' DEEP-OBSERVATION HOLE LOG Hole # TH�.. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Slones,Boulderes. nskjcncy i Graven LoArj 6AN) 2 L (o l0o/a Go�jUS t-crvh 0 1 _ b - G2 IoAM� DEEP OBSERVATION HOLE Lqq Hole# + Y" a Soil :.l+.'t;e �;,;,.,_'Olhery✓.,,^$;`:r.'r;•�i�";. Depth from Soil Horizon Soil Texture Soil Color Mottling Structure,Stones,aoulderes. Surface(in J ,(USDA) (Munsell) 6 (' i i Flood InIMMIULARale Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No_ Yes Within 100 year flood boundary No, Ycs Depthof NAliarallyQccturng Pervious Material Does at least four feet of t1AtgCally occurring pervious material exist in:all area-,;observed throughout the 1 area proposed for the soil absorption system? y,!�-`-7 -- -- i If not;what is the depth of naturally occurring pervious material? . Certification r I certifv 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 training,expertise and experience described in 310 CMR 15.017. i r j e E i I . { DEAN R& MARGARET A. SWIFT i ROBERT G.KING III& ELIZABETH JANE II E ALFRED&JOYCE , 3 67.1.5' L= 171.4 1' i STEIGLEDER c R=2195.00 i 00 io2 1�3 00 98 ' 01015'0 "E 95 2 , i 1 L � IW j 1 1.28 _ 9z SCALE I Q' > I 90 4';4 or LOT 1 N Q I A = 79,693 S.F. I 1.600 AC. ' OF E� OF �yqIF� ��`p�C V�gs�s c' 011- ALLAN �tiG\� HARRY yG C. ;}� EARL —` KINGSBURY yi? LANTERY, JR. _ p #26101 J ,o p No.26575 \ L� j ?� F y 94 ; +4 !q G`sTIf. �� ss T Hp s it r L E, o U -.• PR3PC�E�-L S (�- i 1 c PI AW 194,8Q' ; a O1015'00°w P = s4.22' M. it M. W 1 LL 11A M R I C C r ob roc 4 , ° 9g 345 C A M 1P ST P. C t I- COBBLE STONE ROAD R= 1975.00 WEST `f r V 0`JTE , M\ 02673 40 FEET WIDE o;v � 551=S.�ORS MPP316, PC, 4 9-1 COa LE STONE- ROl-\ D 6A NST\ULEE V I L L Gr A 550 C. TEC I i. :3 u1J S DAT��a I 0-?7� ,�n D W'G. 1 OZ 7 S-1 Fr>v_ FLUo R I , ToP oF•W/aLL. 1=t N_GR.c>,g2:S� I L'L, iat.o� \EAISi JNG GR,EL94.0 kk x xx ,c 11 o T� PAC tom, oJF. J-\LL I i�Q>✓it6l)s + NJ_9n_7 /l/v,L L Q 1.5 LSEA�iT C SC�t E 2oM > _ �I O 13>=L oW P. R L7-1 L E oi; ,D I S I� O S AL SYSTEM - -Nc� ES 139aSr.�L.. 3YS7-cM' i o B� CaMST-2VCTE17 IN S—R\C., 4 CCoap art c.> of 0,.0m rat. or s. F-N v 1Rol-i. CooE-T�-� , 1�, - LCT, �p 3. USE T'r�,`r- S'x8',xI' WI1GGiiJ ri r 'E - - 31'= To i °;r v✓ �5t- S TONE JM f AR �U N .D w, rr-f Z "' of TEST Pt Ts. l�_ ^ Z�- PEA Dr\)= -�- TEsr D 1 p,� h PLAN F 1I510M. -L xf�r1NiS- ozy'�` J J�7. J:C` _ , . .t , '','.�,.� I N API F 1 G RAbL-- 2 g HARRY c,r 3Y �(��^r Gn1 _ �� )ABL MA I ot.0— 1 —94.c7 g EARL �- �' U 1 c.--,. 1� —T LANTERY, 1R. in �= = �. - = _ Lt� .I-5 t r\? L REG . aF YLI_'D� fo0.5 — LoAM ! i g3 5 -p�No.26575�q QG SIGN R ciST - 5A*j0 �� 1 SI NGLE 1=(�,AA Lam/ 0WEL>_11-1 G W4.1/ ��DR o0 M S � 97.o — ,Pepx- M10 G/aRt3 AA G E 101 sPoSA1, —eqo SEW/\6F OISPOSAL SYS j�1v1 DESIGN S1= PT IC TAN►< U Cam, M W 1 LL l-\M R I Cr' I sAvo AVD 340 C1`�t�`? S T t�EE s GRAv�>_ ( WLST `l A\RM OUTH MA OC6T3 C 11 MS E R S I a N v S1' 3 - ox5' WIGiNS L_ C _ f -STONE PSSESsopsM)C 3:p PC. 49 - I I, C01,n TnLZ 3TON) E R01\1 E r E CT IV ?110 _ L _ ()' I - _. BA+�.Iv51 ,�3L� 64•r'26-1X0. 4 3 x 3Z x0..7? 30 _� _ A SS OCQ TECH- S FLU ►IONS OT�L cAPK�� 4I GALS C>rnsv�T, ��G'�z �:5 •� MA . f CSrLv: f0-2Z 9� !, CATE' 10-ZZ- 9S pWG, 10-UT8-Z -- - - . I 1 t 4 DEAN R. & MARGARET A. SWIFT ! ROBERT G.KING III& ELIZABETH JANE "E { ALFRED&JOYCE 67.15' L= 171.41, T STEIGLEDER 3 R=2195.00 — (V � M 98 96 2 010150�"> S ITC PL /� N 1 1 1.28' rot' 92 SCALE . 1 • — 4--0 / \^ r� , .F 4- 2 roq r4' 6Z I;OT ICIO 45 A.— 79,693 S.F. z 38 , r 1.( 00 AC. 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