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HomeMy WebLinkAbout0046 COLLIE LANE - Health j 46 COLLIE LANE BARNSTABLE _ A= 335 - 078 - 002 I Y r f 935- D 7 9- ooc - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane,Cummaquid-Barnstable, MA 02630 S"_ AS Property Address Estate of Marllyn J Kelley Owner Owner's Name, information is Bamstable-Cumma uid MA 026302 '" 10/06/2020 required for every q " 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.Please see completeness checklist at the end of the form. Important:when filling out formsA. Inspector Information on the computer, REID C. ELLIS use only the tab key to move your Name of Inspector cursor-do not ELLIS BROTHERS CONSTRUCTION use the return key. Company Name 23 ENTERPRISE ROAD Company Address YARMOUTH PORT MA 02675 Cityfrown State Zip Code 508-362-6237 S121891 g Telephone Number License Number B. Certification I certify that: I am a DEP"approved system inspector in fulfil compliance with Section 15.340 of Title 5 (310 CMR 15.000); I have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and main Hance of on-site sewage disposal systems.After conducting this inspection I have determined that the stem: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. . ❑ Fails -zie� Inspector's Signature Date, s 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. l5insp.doc-rev.7262018 Title 5 Official hispection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official al Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Barnstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is Barnstable-Cumma uid MA 026302 10/06/2020 required for every q page. cityfrown State Zip Code Date of Inspection C. inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: I have not fou any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: G Y ❑ One or more system components as describ(d in the"Conditional Pass"section need to be replaced or repaired.The system, upon corn letion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined" , N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*o the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltra ion 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 str icturally 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 belo ): t5insp.doc-rev.72812078 Title 5 Official Inspection Form:Subsurface Sewage Disposal S -Pa of 8 �P� 9 Posat System Page 2 1 L Commonwealth of Massachusetts P Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �,• � 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is Barnstable-Cumma uid MA 026302 10/06/2020 required for every q page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): / ❑ Pump Chamber pumps/alarms not operationE I. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out c r 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 eaith): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 firr 3s 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 Soar of Health: ❑ Conditions exist which require further evaluatii in by the Board of Health in order to determine if the system is failing to protect public health, s fety or the environment. a. System will pass unless Board of Healtt determines in accordance with 310 CMR 15.303(1)(b)that the system is not function g in a manner which will protect public health, safety and the environment: 15insp.doc-rev.7126/2MB Title 5 Official Inspection Form:Substaface Sewage Disposal System-Page 3 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is q required for every Bamstable-Cumma uid MA 026302 10/06/2020 page. CityrFown State Zip Code Date of Inspection co Inspection SUMMafy (cont.) ❑ Cesspool or privy is within 50 feet f a surface water ❑ Cesspool or privy is within 50 feet f a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of ealth(and Public Water Supplier, if any) determines that the system is functionii ig in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil 3bsorption system(SAS)and the SAS is within 100 feet of a surface water supply or tribul ary to a surface water supply. ❑ The system has a septic tank and SAE I and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAE and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAE 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 analyst 3, 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 ilure 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 l5insp.doc.rev.726ID18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name. information is required for every Bamstable-Cummaquid MA 026302 10/06/2020 page. Cityfrown State Zip Code Date of inspection C. Inspection Summary (coat.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ VRequired 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. ❑ p 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 i' 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 fe at of a surface drinking water supply ❑ ❑ the system is within 200 fe at of a tributary to a surface drinking water supply ❑ ❑ the system is located in a ipitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone I I of a public water supply well t5insp.doc•rev.71262018 Tdle 5 Official Inspection Fonm Subsurface Sewage Disposal System.Page 5 of 18 Commonwealth monwlrealth of Massachusetts Title 5 Official Inspection Subsurface Sewage stern Disposal Form-Not for Voluntary p Sy o untary Assessments ;J 46 Collie Lane Cumma uid-Barns I q tab e, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is Barnstable-Cumma uid MA 026302 10/06/2020 required for every q page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (coat.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? V 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,,eKciuding 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.7QW018 Title 5 Official Inspection Form:Subsurface a Disp osal posal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form. r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane,Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is q required for every Bamstable-Cumma uid MA 026302 10/06/2020 page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual). 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes [VNo Does residence have a water treatment unit? ❑ Yes If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection El Yes LET No information in this report) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: /°� ./L 61`� I Sump pump? ❑ Yes No Last date of occupancy: A/VU4A"/ 4 Date t5insp.doc-rev.726M18 Title 5 Offudal Inspection Forth:Subsudare Sewage Disposal System-Page 7 of 18 , Commonwealth of Massachusetts p Title 5 Official Inspection For Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is bl t Barnsae-Cumma uid- MA 026302 10/06/2020 required for every q page. Citylrown State Tip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial 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 syste ? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? L ( Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7rA=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name . information is q required for every Bamstable-Cumma uid MA 026302 10/06/2020 page. Cityrrown State Zip Code Date of Inspection De System Information (cont.) 4. Type of ystem: 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/Altemative 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: 77 Were sewage odors detected when arriving at the site? ❑ Yes VN o 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): r Distance from private water supply well or suction line: loq-9y feet Comments(on condition of joints,venting,evidence of leakage, etc.): /'X/4CO4 ct-1 t5insp.doc.rev.7I26MM 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection For I� Subsurface Sewage Disposal Systems Form-Not for Voluntary Assessments ,. � 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is Barnstable-Cumma uid MA 026302 10/06/2020 required for every q page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) 6. Septic'Tank(locate on site plan): Depth below grade: feet Material of construction: �ncrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) f If tank is met/a17 e: "cerfific N� Is age co rme .Certificate of Compliance? (attach a copy, ❑, es ❑ o Dimensions: j�, v� ' /�� "�` Z Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle v pit Scum thickness Distance from top of scum to top of outlet tee or baffle C.3 Distance from bottom of scum to bottom of outlet tee or baffle " How were dimensions determined? =°'`' L Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): `Q�e� �` �Y ��1� .v'�=e�I'✓t�. L.�..9�'� �• a3,°' ��j� - ✓ `�7 9 t5esp.doc.rev.M62018 Title 5 Official Inspection Form:Subswlace Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Offidual Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is Bamstable-Cumma uid MA 026302 10/06/2020 required for every q , page. City(rown State Zip Code Date of Inspection De System Information.(cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal E I 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 butlet 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, evidE nce 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 ❑f berglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons .Design Flow: gallons per day t5msp.doc•rev.7rISMI8 Title Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 18 i f Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is q required for every Bamstable-Cumma uid MA 026302 10/06/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) 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 switct es, etc.): Attach copy of current pumping contract(re ired). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): , Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence o lids carryover, any evidence of leakage into or out of box, etc.): N= t5insp.doc-rev.7/2 612111 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Disposal Sewage g p sal System Form a Not for Voluntary Assessments 4 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is Bamstable-Cumma required for every Quid MA 026302 10/06/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ` 10. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, I stem'is a conditional pass. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type- leaching pits number. �. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: t5insp.doc•rev.7/M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane,Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is q required for every Bamstable-Cumma uid MA 026302 10/06/2020 page. City[rown 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.): 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.): t5irnp-doo•rev.MUMS Ti9e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .;.V 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is q required for every Bamstable-Cumma uid MA. 026302 10/06/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (font.) 13. Privy(locate on site plan): /-1w Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hyd mulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc-rev.726W18 Tdle 5 Official Inspection form:Subsurface Sewage Disposal System-Page 15 of 18 II Commonwealth of Massachusetts a (PTitle 5 Official Inspection r tr Subsurface Sewage Disposal System Folmrs-Not for Voluntary Assessments a• 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is Barnstable-Cumma uid MA 026302 10/06/2020 required for every q page. Cityfrown 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 land arks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the uilding. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately r C 1S�J 2- J. �� w 6,3. h �I i t5'msp.doc-rev.7fMM18 Title 5 Official Inspection Form:Subsurface Sewage Deposal System-Page 16 of 18 Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Barnstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owners Name information is q required for every Bamstable-Cumma uid MA 026302 10/06/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cons.) 15. Site Exam: W,f( heck Slope ©,Surface water Check cellar J Shallow wells Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: F ❑ 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 USGSS database-explain:, You must describe how you established.the high ground water elevation: 95 Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2812D18 Title 5 Off ial Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ? 46 Collie Lane,Cummaquid-Bamstable, MA 02630 -'� Property Address Estate of.Marllyn J Kelley Owner Owner's Name information is Bamstable-Cummaquid MA 026302 10/06/2020 required for every City/Town State Zip Code Date of Inspection page. E. Report Completeness Checklist Co mpl to 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 checked r` 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 t5msp.doc•rev.7126MIS Tine 5 official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 i W.VERNON WHITELEY, INC W. V E R N O N PO Box 1266 West Chatham; MA 02669 Ilvc. �' PLUMBING o HEATING AIR CONDITIONING INV E Bill to: Kelley, Mark Invoice Date: 10/07/20 1500 Mary Dunn Road Invoice;: 00051593 Barnstable, MA 02630 Terms: Net 15 Service at: 46 Collie Lane,Yarmouth Port Work order: WO-00067000 Reason: Remove garbage disposal Work Performed: Removed garbage disposal Product Date Comment Quant I Unit Price Disc% Amount. Technician-Service Labor 10/06/20 1 1 1.001 130.00 1 100 1 $0.00 TOTAL DUE: $0.00 Courtesy discount of $130 reflected in total due. Thank you! Please Note: Effective January 1, 2019, we have transitioned to email delivery of invoices and statements. The email address we have on record to send your invoices and statements to is: Please contact our,office to update your email address and with any questions you may-have. Thank you! Phone: (500)945-1100 "Family Owned Since 1952** www.wvwhiteley.com Reid enclosed is bill for removing the garbage disposal at 46 Collie Lane Cummaquid. Thank you for your help. Mark Kelley 1500 Mary Dunn lad Barnstable Ma 02630 508-328-6463 335- 0 9--�0-00 aa- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface,Sewage Disposal System Form-Not for Voluntary Assessments f , Y � 1 46 Collie Lane, Cummaquid-Bamstable, MA 02630 sSr Property Address Estate of Marilp J Kelley Owner Owner's Na -' information is required for every Barnstable-Cummaquid -MA 026302 .- 10/06/2020 page. City/rown 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. Inspector Information Sly ! on the computer, REID C. ELLIS use only the tab key to move your Name of Inspector cursor-do not ELLIS BROTHERS CONSTRUCTION use the return Company Name key. 23 ENTERPRISE ROAD Company Address YARMOUTH PORT MA 02675 Cityfrown State Zip Code 508-362-6237 S121891 r. Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 16.000); 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 main nance of on-site sewage disposal systems. After conducting this inspection I have determined that the ystem: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Insp or's Tignature 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.712612DIS Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 46 Collie Lane, Cummaquid-Bamstable, MA 02630. Property Address Estate of Marilyn J Kelley Owner Owner's Name information is Barnstable-Cummaquid MA 026302 10/06/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1 j System Passes:rany I have not founformation 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: r 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*o r the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltra bon or tank failure is imminent. System will pass inspection if the existing tank is replaced with a c)mplying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is sti ucturally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 2 years old is available. ❑ Y ❑ N ❑ ND(Explain bell: ): t5insp.doc•rev.726J2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is required for every Barnstable-Cummaq uid MA 026302 10/06/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ,/� 2) System Conditionally Passes(cont.): r ❑ Pump Chamber pumps/alarms not operation 31. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out r high static water level in the distribution box due to broken or obstructed pipe(s)or due to a b oken, settled or uneven distribution box. System will pass inspection if(with approval of Board of ealth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replace ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval I 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 °f Health: ❑ Conditions exist which require further evalu bon 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 Hea th determines in accordance with 310 CMR 15.303(1)(b)that the system is not functi ning in a manner which will protect public health, safety and.the environment: t5insp.doc•rev.7 AMI8 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 1_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � % 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is required for every Barnstable-Cummaquid MA 026302 10/06/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) Cesspool or privy is within 5f'of a surface water ❑ Po P � ❑ Cesspool or privy is within 50 fe t of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board c f Health(and Public Water Supplier, if any) determines that the system is functio ning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank ands it absorption system(SAS)and the SAS is within 100 feet of a surface water supply or trit utary to a surface water supply. ❑ The system has a septic tank and S S and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S S and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S S 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 anal sis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the pi esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no othei 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `:`L/ 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is Bamsable-Cumma uid MA 026302 10/06/2020 required for every t q page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El Static liquid level in the distribution box above outlet invert due to an overloaded or cloggedSAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ Required pumping more than 4 times in the last year 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 correctXthefa' re. ./45) Large Systems: To be considered a arem 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 4 0 feet of a surface drinking water supply ❑ ❑ the system is within 2 0 feet of a tributary to a surface drinking water supply El El Area system is located n a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a m pped Zone II of a public water supply well t5msp.doc•rev.7/2WO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley 'Owner Owners Name information is required for every q Bamstable-Cumma uid MA 026302 10/06/2020 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health Were an of the system components pumped out in the previous two weeks? ❑ Y Y Po P P ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? El available as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components,�Wc luding 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? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is q required for every Bamstable-Cumma uid MA 026302 10/06/2020 page. City/Town. State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): � ® Description: c � Number of current residents: D s r denceshave a g rbage g4hn Yes ER/No Does residence have a water treatment unit? ❑ Yes 00'/No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: h� Sump pump? ❑ Yes M No Last date of occupancy: /�AlZ1A Date t5insp.doc-rev.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is bl t Barnsae-Cumma uid MA 026302 10/06/2020 required for every q page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) r'�+ 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 syste ? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: P g _ Source of information: Was system pumped as part of the inspection? [5 Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ��' t5insp.doc•rev-7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane; Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is required for every Barnstable-Cummaq uid MA 026302 10/06/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type 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/Altemative 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: l Were sewage odors detected when arriving at the site? ElYes WNo 5. Building Se er(locate on site plan): Depth below gfadb: ,.- e4 11W &L, Material of constructio;/40 cast iron PVC ❑other(explain): Distance from private water supply well or suction line: ' feet Comments(on condition of joints,venting, evidence of leakage, etc.): , t5insp.doc•rev.U 2018 Tate 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r^ Title 5 Official Inspection Form w� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 u Property Address Estate of Marilyn J Kelley Owner Owner's Name information is Bamstable-Cummaquid MA 026302 10/06/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: j feet 7Mat al of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) 74 . ,If tank is eta l, ist a / g years /�'' 4 Is ag confirmed by Certificate of Compliance?(attach aZDVof certi sate) Yes No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle c Scum thickness r� Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle R 1 How were dimensions determined? �� M Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): .3 t5insp.doc•rev.V26=18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Barnstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is required for every Ba mstable-Cumma quid MA 026302 10/06/2020 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 ot itlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, i let 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 pump d at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal F fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Barnstable, MA 02630 `V Property Address Estate of Marllyn J Kelley Owner Owner's Name information is Barnstable-Cummaquid MA 026302 10/06/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 8. Tight or Holding Tank(cont.) A4 Alarm present: ❑ Yes ❑ No Alarm level:. Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switct es, etc.): Attach copy of current pumping contract(req ired). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of ids carryover, any evidence of leakage into or out of box, etc.): J 150— � A t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is required for every Barnstable-Cummaq uid MA 026302 10/06/2020 page. C4frown 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 chambe , condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working orde , system is a conditional pass. -11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number leaching chambers number: ❑ leaching galleries number: , ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ . overflow cesspool number: ❑ innovative/altemative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 18 i4 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane,Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Flame information is q required for every Bamstable-Cumma uid MA 026302 10/06/2020 page. Cityrrown 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.): D .0 12. Cess000l (cesspool must be pumped ag p 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 by(raulic failure, level of ponding, condition of vegetation, etc.): t5bsp.doc•rev.7262018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �� 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is Barnstable-Cumma uid MA. 026302 10/06/2020 required for every q 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 1,ydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marllyn J Kelley Owner Owner's Name information is Barnstable-Cumma uid MA 026302 10/06/2020 required for every q 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 uiWing. Check one of the boxes below: Ahand-sketch in the area below ❑ drawing attached separately g J 33 i a t, �. t5insp.doc•rev.MW018 Tgle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal - g �sposa System Form Not for Voluntary Assessments 46 Collie Lane,Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is Barnstable-Cumma uid MA 026302 10/06/2020 required for every q page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: i 6,,Check Slope �] ;:Surface water Check cellar Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked.with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must�s&beow ou established the high ground water elevation: 3, 3 (l Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f 46 Collie Lane, Cummaquid-Bamstable, MA 02630 Property Address Estate of Marilyn J Kelley Owner Owner's Name information is q required for every Bamstable-Cumma uid MA 026302 10/06/2020 page. Cityfrown 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 W.VERNON WHITELEY, INC W. VERNON PO Box 1266 q,VO West Chatham; MA 02669 r^ INC. PLUMBING HEATING AIR CONDITIONING INVOKE 13111 to: Kelley, Mark invoice®ate: 10/07/20 1500 Mary Dunn Road Invoice#: 00051593 Barnstable, MA 02630 Terms: Net 15 Service at: 46 Collie Lane Yarmouth Port Work order: WO-00067000 Reason: Remove garbage disposal Mork Performed: Removed garbage disposal Product Date Comment - Quant I Unit Price Disc% Amount Technician-Service Labor 10/06/20 1 1 1.001 130.00 1 1001 $0.00 TOTAL DUE: $0.00 Courtesy discount of $130 reflected in total due. Thank you( Please (Vote: Effective January 1, 2019, we have transitioned to email delivery of invoices and statements. The email address we have on record to send your invoices and statements to is: Please contact our office to update your email address and with any questions you may-have. Thank you! Phone: (500)945-1100 **Family Owned Since 1952** www.wvwhiteley.com , Reid enclosed is bill for removing the garbage disposal at 46 Collie Lane Cummaquid.- Thank you for your help. Mark Kelley 1500 .Mary Dunn Rd Barnstable Ma 02630 508-328-6463 TOWN OF BARNSTABLE G LOCATION CvmMAC2 ut.0 SEWAGE # �3-109 VILLAGE z%(a (� j�� �,� � ASSESSOR'S MAP & LOT 131;•S79oo!Z INSTALLER'S NAME & PHONE NO. PP-OS aiy & SEPTIC TANK CAPACITY ),000 •f 15 00 LEACHING FACILITY:(type) pf�- }- 2 �YjJv ' (sue) ).60 c� NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: �JZ ,6 3 DATE COMPLIANCE ISSUED: � VARIANCE GRANTED: Yes No V y �� �W I � o a°' . �� ���' o y , C� t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE' Appliration for Disposal Works Tnnitrnrtiun ramit Application is hereby made for a Permit to Construct (;/I or Repair ( ) an Individual Sewage Disposal System at: 10T 8 ............. ---- - -.........-- �N - ....... -----------....-------•-------...............•........-•---•--- Location-Address �o or Lot No. Owner Address .... 2L1................ ------•----•-----------------•-------------•--------. �4:.'.-...J ..../'.. .....----...........------ Installer Address UType of Building Size Lot_- 7_D� ____.Sq. feet ,-t Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) "Other—Type of Building No. of persons............................ Showers a g P ( ) — Cafeteria ( ) Otherfixtures ------------------------------------•-----------------.-------------------------------------------------- ------ W Design Flow..........-6-3.........................gallons per person per day. Total daily flow___......33� .................gallons. 04 Septic Tank Z' Liquid capacity_/AAu.gallons Length.A/4.y_._.. Width. �6��._ Diameter---------------- Depth.---------- W Disposal Trench—No........4.......... Width...... '_.___. Total Length,.....z ..... Total leaching area....3G4......sq. ft. x Seepage Pit No........... -------- Diameter.....k z_....... Depth below inlet..... ............ Total leaching area... M2.4:_sq. ft. z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by--------.`✓ -----,C.:--. ............ Date._ 7g:..zt..� W 14 Test Pit No. 1...L. Z__minutes per inch Depth of Test Pit...i� Depth to ground water...... ............. 44 Test Pit No. 2---4..Zn_minutes per inch Depth of Test Pit.___ .._.. Depth to ground water......................... O Description of Soil----����_�6 '`J ����-LB�� `S/�'`t® '.ScvB-S'est -•----Z....�=--ea st �`s -- ..... % U S. ---------�a-'t-.ff '---Co/a'r��-_S,9uv--- /E��. -` 4'!-/ .......r-G l _.5'A?vo... W U Nature of Repairs or Alterations—Answer when applicable...... ..... ..... :....-__....._..___._._...__..._..._.......__..... ---------- ------- •-----------------------------------------------•-------.--.--------- ,�`mow Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environme ode—The undersigned further agrees not to place the system in operation until a Certificate of Co � li as been issVe board of health. Signed ---------------------------•-- ................................. Date ApplicationApproved BY .. ----- ..............................---------------------------......................... ----- re Application Disapproved for the following reasons- ---------------------- ------------------------------------------------------------------................................-------- -----------------------------------------................------------------------------------------------------------ ---------------------------------------------------------------------------------- ........................................ �p Date PermitNo. ��J.-:-..---/D--,c --------------_------_ Issued -------------------------------------------------------- --- -------- Date y No.. ...: A 7 Fim ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appl ration for Disposal Works Tonstrn.rtinn 1rrmijt Application is hereby made for a Permit to Construct (b4 or Repair ( ) an Individual Sewage Disposal System at: _W 4~ G'ri F3 ..... ................• •- `"�!IAG�u l� - �`!---- --•---------------------•-----1'�r - .......................___--_------------- Location.Address •-or Lot No. L�W,gi�� . G� 4:; ,A�.!�...... __...---•----------------- .... _ .. -------------------------------------- Owner Address w G-Z �s o s ..................X ........ G •u�•r�/?�-�L T - InstallerAddress Type of Building Size .....S feet ._, Dwelling—�No. of Bedrooms........... -------------_-_---___-___Expansion Attic ( ) Garbage Grinder ( ) Othet:;-Type of Building No. of persons............................ Showers — Cafeteria 'Other fixtures ------------------------------------•--•---•----------.-----------------•-------------•-----------•----•-----.........__.... W Design Flow...............T...........................gallons per person per day. Total daily flow--------- S3d----_--................gallons. R: Septic Tank Z' Liquid capacity_/o�_gallons Length_g'_�'_..... Width.' .G"".. Diameter................ Depth..iV9'*. W Disposal Trench—No........Z.._...___. Width__•.../z._..... Total Length..-.•.L4�..._ Total leaching area----3G4------sq. ft. x 3 Seepage Pit No..................... Diameter-----/Z_._..._. Depth below inlet-----G........... Total leaching area....332.3_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by..&Vk/,1"z,0_..._.�_____________________________ Date... E8_.Z3 .. a Test Pit No. 1.... ..........minutes per inch Depth of Test Pit--- Depth to ground water.._."! ............ f1 Test Pit No. 2.... ..Z..minutes per inch Depth of Test Pit---- Depth to ground water-----................ ----•-----------------------•------•------•---.......--•-•-•----------._......_-•-•---•----•--••--•......................................................... 0 Description of (j Soil----O"_&" 40A_I 14�1-48��_ 44! o xA . - aD X4 vp f'C%Z4V&Z='SJvTB4-,1S-vi¢�-. .... - . - ! LP'�=••Lv Cq sc".. .. W UNature of Repairs or Alterations—Answer when applicable............................................................................................. -•------------------------------------------.------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmen a Code—The undersigned further agrees not to place the system in operation until a Certificate of Co lia� as been issu d by,the board of health. Signed ....................... ------------ .. = Dare Application Approved B Application Disapproved for the following reasons: ---------------------------------------------------------------------------------------- --------------------------------------------- - -------- -----------------------------------------------------------------------------------------------------------------------------------------' ............. ---------------.--- Dare PermitNo. ..---,�n--.3..........lo--?............................. Issued ................................. Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C9ertifir xte of Contylianve THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( �r Repaired ( ) by...................... --------- ----------------------------------------------------------------------...--........-------------------------------------------------------...------------------------------------ WInstaller has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......... .... .. ......... dated ............................-"..-----........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................- z.� •. Inspector ------....... ...` �1... ------------------------------------- .';� -- -------f--�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No-_9-- - -6- TOWN OF BARNSTABLE FzE...ln )-.---•--.•- Disposal Works "unstrudion f remit Permission is hereby granted.--------. ...........d`�.. .........................................................................•-•--..........._.. to Construct V or Repair ( ) an Individual Sewage Disposal System atNo...............y4.:--•-• ' �;-..... ............ e <.c s.. ....-------------------------------•---..............--•--........----•---........-•----... Street as shown on the application for Disposal Works Construction Permit No. J_ _ .. Dated.......................................... _7*1) ..... _ DATE_ 3...... Z::;;.3 Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS �--- EL.. L3,9/ . T7 TOP OF FOUNDATION L .'.. TOP OF FOUNDATION :�' CONCRETE COVERS CONCRETE COVER ' 4 CAST I R O N � 7- � CONCRETE COVERS �; OR SCHEDULE 402 MAX. 4' SCHEDULE 40 PV.C. (ONLY) •- PVC. PIPE MIN. 12 MIN. /g • ' . _ PITCH I/4' PER.FT. PIPE- MIN. PITCH 1/4' PER.FT LEACHING TRENCH (......REQUIRED) �9' 4"CAST IRON 2"MAX. 12"MAX r _•. I/B"-f2�• WASHEDRSTONE 4 OR SCHEDULE 4t� 4"SCHEDULE 40 PVC (ONLY) I PVC. PIPE PIPE MIN. LEACH o''. INVERT `n n� n�+� n n n /i iL PITCH I/4"PER. e+ EL INVERT( INVERT INVERT r� n �i n n r_r.f�r��!"1 PITCH I/4"PER.FT PIT SEPTIC TANK DIST. E, �o.i7 N Z° PRECAST •; EL x/ �� FLOWDIFFUSORS NVERT a LEACHING INVERT { ,0on BOX '', < N 2G GAL. � INVERT-� \ � e EL.. Z/ ZZ INVERT INVER . . .•� PIT OR •, E'er.. . t EL.I.o_•_34 INJ�RT INVERT SEPTIC TANK DIST. w S.L7 t EL..10.7L EL; Z >_ ��; EOUIV. INVERT BOX ,,, T EL q 7� E;L. 9 9.7 fin, /ono GAL. INVERT c Ua q •• I ' A(3ovt EL... �. . EL2o.5"9 INVERT � ' ww q .•. 3/4"TO IV2� EL4o.ov �." WASHEDU. • w cz STONE1-4 I G 4 •' / —�{ 8 c� �4.°` PROFI LE OF GROUND WATER TABLE •.. . �— /L DIA '`+ SOIL LOG SEWAGE DISPOSAL SYSTEM TYPICAL CROSS SECTION • •' PROFI LE OF -GROUND WATER fADL;- DATE F�r.�j.!7� TIME .A" . No SCALE LEACHING TRENCH S�`! 7-4 A„' � 1 NO SCALE N�NE e�'Coa vTtYEG TEST HOLE I TEST HOLE 2 SEWAGE DISPOSAL SYSTEM DESIGN DATA : - - ELEV. ./G. �� . . .. . . . . . . . ELEV. . . . . . . . . . NO SCALE 12"MIN. f ✓Q NUMBER OF BEDROOMS 1. . WASHED /8 N- ,,.I• . . . . . . . . S70N E TOTAL ESTIMATED FLOW GALLONS/DAY — 4 SOI L LOG WITNESSED BY . $'" �• ij•77 BOTTOM LEACHING AREA t38 s SQ.FT./TRENCH:! LL DATE 3 �y%�-` TIME //:'�U qP1 TE-k2`/ j,A, 1' . ''. BOARD OF HEALTH cbwusL' -� ���' -A"/'° SIDE LEACHING AREA . . . . .. . . . . .. . . SOFT./TRENCH „ __ tz.. //./0 -----Z3/4 -11/2 TEST HOLE I TEST HOLE 2 EDl.1/tiiN10 �� �Lt"'�/. ENGINEER GARBAGE DISPOSAL . .^/�^l�. .(50% AREA INCREASE) WASHED ELEV. ELEV. 23 �� . . \ a«o +/lI►VkL STONE 7c` °y �' �• TOTAL LEACHING AREA 3�0. v SO.FT. I 8.61t y�- — FL.. 9.icy . . . . .. (� ,� —+1•,�—c. � A�SOvE /! 7� irwD 77 DESIGN DATA PERCOLATION RATE q".7?'''�?^�/PER. INCH _ LEACHING AREA PER PERCOLATION RATE " '�• `'. SO.FT./•.,); - eZ. 0 71 NUMBER OF BEDROOMS te" S qNv TOTAL ESTIMATED FLOW Zzo. GALLONS/DAY / I /1 GROUND WATER TABLE ,4./o T I,1//V ofA,e�/ST�QG� 1<+yexs �F BOTTOM LEACHING AREA // SO.FT. /PIT ��' �% '. . .WATER ENCOUNTERED �'oA. �►,�4 2ZG. z .9,eCq, = /3 �C zS = 3 z S _s ,cam o• 7.s= ' r . 7, n,✓� a/avy� SIDE LEACHING AREA SO,FT./ PIT p C GARBAGE DISPOSAL No NE (Sp % AREA INCREASE) Nev. TOTAL LEACHING AREA SOFT SAr,�p PERCOLATION RATE .4_�:.f T,t.ur.i MIN/INCH - - ' cz.//./o LEACHING AREA PER PERCOLATION RATE `'7 G SO.FT.� t� ,� -v 4 �i� //o WATER ENCOUNTERED NUMBER OF LEACHING PITS d!✓� ��7 b/' ,N "� 3z� _ Y LL -1 it^ Iti Tl/� =� Of 7DNE A. ALA /Q�1 / 1F IE ` / / / ►° e APPROVED . . . . . . . . . . BOARD OF HEALTH . . -- \ 14' DATE 6 a,� J +"i �' �/ LOT A l /+ • AGENT OR INSPECTOR � -___r 16 - - _ __-- I .��✓ � � �,/ /. Sio Ac,et3 ,e' / j �, / / l 1 oe L �l . le-1.LcY '�' a r^ 3•/ �� - ' < «.� 7Nn /� , 0 P15r tv r / :.ls/y M/��is/ •M�. "D >~ �L LfR�� .t E.r,E'i�•V ` 1 ..-•- .' ' D e.1.r d PETITIONER C L4- <' 8/ A1.e1~st'/Lfry .I I�E G�.t`� / �M4n�IRM x -- I t / �7E r. z \ / /T7 -sex-,TdNJK / /2 'r .� M O � � /�.� / •6y _ / Iki 7`te/° ituw-D/FFvSuas � / � �1 1. / E r k � Qj N L07 40/ f t>. / E" / C l7?J /.v �A.Pit/-S.T/-,�B!cC f//�,r,AP¢i Ifs• Z 'f4 -7