HomeMy WebLinkAbout0417 COMMERCE ROAD - Health 417 Connnerce Road
Barnstable
A= 317-- 020
i
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I
Commonwealth of Massachusetts. I
a Title' 5 Official �Inspect'®n F®rrri
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
417 Commerce Road, Barnstable'
Property Address -- --
Laura F. Ware- M_cGourty _
Owner Owner's Name
information is required for every 25 Campion Road, Yarmouth Port MA 02675 June 4, 2009 -
—�— -- •
page. City/Town State Zip Code Date of Inspection
Inspection fesults,mu$t be submitted on".this form. Inspection forms may not be altered in any
way.
Important:When '
filling out forms A. Gelleral Information
on the computer,
use only the tab 1: Inspector:' -
key to move your
cursor-do not Troy Williams
use the return key. Name of Inspector
Troy Williams Se tp is Inspections
rab - Company Name
19 Hummel Drive
Company Address -- ------- - — i
ra� South Dennis _ MA r. 02660
Cit jown State Zip Code
Y. a
508) 38-5_1300 -- _: S1682 ---
`Telephone Number License Number -
B. Certification
`certify that l 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: a'
® Passes ❑ Conditionally Passes ❑ Fails
Needs Further Evaluation by:the Local Approving Authority
. �, June 4, 2009 `
Inspector's Signatu a 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'101000 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 4
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 it that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use..
417 Commerce Road.Barnstable•03/08 Title 5 Official Inspection Form:Subsurfacesewege Disposal System•Page of 15
Commonwealth of Massachusetts ..
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
417 Commerce Road, Barnstable
Property Address
Laura F. Ware-McGourty
Owner Owner's Name,
information is 25 Campion Road Yarmouth Port MA 02675 -June 4,2009
required for every ,p - - — — -
page. City/Town _ r State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Checki A,B,C,D,or`E/always complete all of Section D
. A).-.System Passes:: �.
N%I have not found'any'information which indicates that any of the failure'criteria described
in 310 CMR 15.303 or in 310 CMR,15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
,System meets minimum-standards set by Mass 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.
B) System,Conditionally Passes:
❑ One or more system components as'describ6d 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.
. .r
Answer yes, no or not determined,(Y, N. ND) in the ❑for the following statements. If"not
determined," please explain.
The septic tank is metal and over'20 years old* or'the septic tank(whether metal or not)'is
structurally unsound, exhibits.substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the.Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank'is less than'20 years old is available:.
ND Explain: .
_ — Q
❑ Observation of,sewage backup or break out or high static water level in the distribution box:due
to broken or obstructed pipes)or due to a broken, settled or'uneven distribution box: System will
pass inspection if(with approval;of Board of Health)
broken pipe(s) are replaced
❑ obstruction Is removed
ti 417 Commerce Road,Barnstable•.03/08 Title.5 Official Inspection Form:Subsurface Sewage Disposal,System+Page 2 of 15 ,
Commonwealth of Massachusetts
Title 5 official h ecti®n dorm
a Subsurface Sewage Disposal System Form No for Voluntary Assessments.
417 Commerce Road Barnstable
-- dres -
Property Ad s
P Y
Laura F. Ware- McGourty
Owner Owner's Name —
information is 25 Cam ion Road Yarmouth Port. MA-- 02675 . June.4,•2009
required for every �—_—s — -
page. City/Town State Zip Code Date of inspection:
B. Certification. (cont.) -
B) .System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
f
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).
El broken pipe(s) are replaced
❑ obstruction is removed
ND Explain: M
N/A
C) Further Evaluation is Required by the Board of Health: x
❑ 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'wrill pass.unless Board of.Health determines in accordance,with 310 CMR
15.303(1)(0)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
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has aseptic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ " The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
i supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well. . ,.
417 Commerce Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 15
Commonwealth of Massachusetts
-- aTitle ,5 64iciall i5pecti6n Fol rrn
Subsurface Sewage.Disposal;System Form -Not for Voluntary Assessments
a, 417 Commerce Road, Barnstable
Property Address -
Laura F. Ware-'McGourty
Owner Owner's Name —information is 25 Campion Road, Yarmouth-Port MA 02675 June 4, 2009 .:
required for every P — - —
page. Cityrrown State Zip Code Date of Inspection
s
B. Certification (cont.)
C) Further Evaluation is Required by_theeBoard 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 s stem asses if the well' 'Water anal sis, performed at a'DEP certified laboratory, for coliform -
Y P Y P , . rY
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:., k.
3. Other:
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
Q ® Backup.of sewage into facility`orsystem component due to overloaded or..
clogged SAS or cesspool Y '
❑ ® arDischarge or ponding of:effluent to the surface}of the,ground or surface waters
Aue.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 1/.day flow
Required pumping more than 4 times in the last year NOT due to clogged or
❑ ® .
o m e Nu b r f timespumped: R .obstructed plpe(s).
❑ M Any portion of the SAS, cesspool or privyis,below high ground water elevation.
i
Any portion of cesspool o`r privy..is within 100 feet of a surface water supply or
❑h r
tributaryto`a surface water sup
417 Commerce Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
i
r
Commonwealth of Massachusetts-
Title 5 Official Inspection"Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
417 Commerce Road, Barnstable
Property Address -- - - ---
Laura F. Ware-McGourty
Owner Owner's Name
information is 25 required for every Campion Road, Yarmouth Port x' . MA, 02675 June 4, 2009
— -- — -
page. CityTrown State Zip Code Date of Inspection
B. Certification..(cont.j
•D) System Failure Criteria Applicable to All 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.
❑ M Any portion of a cesspool or privy is less than 1.00 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 2001eet of a tributary to a surface drinking water supply
n the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area-1 IWPA)or a mapped:Zone ll of a public watersupply 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.
417 Commerce Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
.. - 4 - -
Commonwealth of Massachusetts
Title. 5 .Official.yInsp6dibn Forte
Subsurface Sewage Disposal System Form,,--Not for Voluntary Assessments
H 0 417 Commerce Road, Barnstable
r
Property e
P Y Address
^
Laura F. Ware -McGourt ._'
Owner Owner's Name -- -- - - -
Information Is
25 Campion Road Yarmouth Port MA 02675 June 4'2009 -
required for eve p --- — _
page_ CityrFown r r State w 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? -.
r
n. Were as built plans of the system obtained and examined?.(If they were not
® available note as N/A)
M.' ❑ Mas the facility or dwelling inspected for signs of sewage back up? `
® ❑ ` -Was the site inspected for signs of break out? n
®; ❑; Were all system components'excluding the SAS, located on site?'-
M ❑ 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.
ElDetermined 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))
417 Commerce.Road,Barnstable•03108- Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 15
4 ^
i "
Commonwealth of Massachusetts'
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
417 Commerce Road, Barnstable
Property Address
Laura F. Ware-McGourt a
Y
Owner Owner's Name
information is p required for every 25 Cam ion Road, Yarmouth Port. MA 02675 June 4, 2009
— - —
page.. Cityrrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design):. 3 Number of bedrooms (actual): 2.
DESIGN flow based on 310,'CMR'15.203 (for example: 110 gpd x#of bedrooms): .330 gpd
Number of current residents: 0 (1 prior
past 12 yrs)
Does residence have a garbage grinder? ❑ Yes M No
Is laundry on.a separate sewage system?[if yes.separate inspection required] ❑ _Yes ® No
Laundry system inspected? ❑ Yes' M No
Seasonal use? ❑,Yes '® No
• Water meter readings, if available last 2 ea`rs usa e d 08=2,000gals
9 ( Y 9 (gpd)): 07=13,000gals
Sump pump? ❑:Yes ® .No
Last,date of occupancy: Vacant 1 year
r Date
Commercial/Industrial Flow Conditions:
N/A
Type of Establishment:
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq`ft., etc:): N/A
Grease:trap present? ❑� Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
{
Water meter readings, if available: N/A`
Last date of occupancy/use: N/A
Date
Other(describe): N/A
417 Commeice Road,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 or 15
Commonwealth of Massachusetts
F Title 5 `Official Inspection» Form X
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
417 Commerce Road,-Barnstable
Property Address -- --
Laura F. Ware- McGourty:
Owner Owner's Name — ----
information i 25 Campion Road, Yarmouth•Port MA 02675 June`4,2009
e '
required for every —
page. City/Town State Zip Code Date of Inspection-
}
D. System Information (cont.) t
' General Information -
Pumping Records: t
} No_purqping,info was available.
Source of,information: —
Was system pumped as part of the inspection? El
Yes ® No
N/A
If yes, volume pumped; -- -- —
_ gallons.,`
How was quantity pumped determined? N/A _ -
Reason for:pumping: N/A - — — —
Type'of System: _ E
® Septic tank,'distribution box, soil absorption system
Single`cesspool
- ❑b Overflow cesspool
❑' Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records,,if any)
El In technology. Attach a copy 6liof the current operation and
x maintenance contract(to be obtained from system owner) and'a copy of latest ,
inspection of the I/A system by system operator under.contract -
i ❑ 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& leachingwere installed on 10/7/92 per compliance'.
Were sewage odors detected when arriving at the site? ❑ Yes No.
417 Commerce Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page.B,of 15
Commonwealth of Massachusetts l
Title 5 ®ffidal th'spedi®n Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
417 Commerce Road, Barnstable '
Property Address
Laura F. Ware- McGourt+__
Owner Owner's Name — -- --
information is 25 Cam ion Road,Yarmouth Port MA 02675 June 4, 2009
required for every p — — ,
page. CitylTown .. State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
18"+
Depth below grade: feet
Material of construction;
❑ cast iron M 40 PVC ❑ othe,r(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):
,I.
10"
Depth below grade: y
, feet
Material of construction:
® concrete ❑ metal ❑fiberglass polyethylene ❑ other(explain)
Y If tank is metal,'list age: N/A
years
Is age confirrhed.by a Certificate of Compliance?.(attach a copy of certificate) El Yes El No
------------------------------------------------------------------------------------------------=--------- ---------------
Dimensions: 5'X 9'X 6'. 1000 gallon
Sludge depth: 4„
2, 8,
Distance from top of sludge to bottom of'outlet tee or baffleV.
---
Scum thickness ---- —
R. 6"
Distance from top'of scum to top of outlet tee or baffle —
. 13„
Distance from bottom of scum to bottom of outlet tee or baffle ----
How were dimensions determined? Probe Measured
417 Commerce Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts -
e I fi Title cea I i ns ect on'�F rrn
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,
417 Commerce Road, Barnstable
Property Address L
Laura F. Ware-McGourty
Owner Owner's Name
information is 25 Campion Road, Yarmouth Port . MA 702675 June 4, 2009
required for every _ P • ,
page. City/Town State Zip Code Date of Inspection
D. System Info rmation.(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.):
Pvc inlet and concrete outlet tee were present. No evidence of leakage.or-damage was found.
Grease Trap (locate on site plan):
Depth below grade: N/A
feet -
Material of construction:
El concrete. [❑+metal z El fiberglass ❑:polyethylene ❑ other(explain):
N/A
Dimensions::. . N/A
Scum thickness . .N/A y ,
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;
N/A
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.): 4
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
•N/A
Depth below grade: —
. d
Material of.construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
N/A'
417 Commerce Road,Bamsfable•03/08 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Orispecti ' n Form
Subsurface SewageDisposal System Form - Not for Voluntary Assessments '
417 Commerce Road,.Barnstable
Property Address
Laura F. Ware-McGourty j
Owner Owner's Name s
information is p
required for every 25 Campion Road,,Yarmouth Port F MA 02675 June 42009
page. Cityrrown State Zip Code Date of Inspection
D. System Information (coat:) h
Tight or Holding Tank(cont.)
Dimensions N/A _
Capacity: N/A
gallons
r l
Design Flow:
.. g _ gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ yes ❑ No
Date of last pumping: N/A
s Date
- Comments(coridition of alarm and float switches, etc.):
N/A
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,any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was found level and in working order with good flow through to leach pit.
` Pump Chamber(locate on site•plan)-.
Pumps in working order: ❑ Yes ❑ No
Alarms in working order j El..Yes ❑ No
417 Commerce Road,Barnstable•03/08 ,Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 15
$•
Commonwealth.of Massachusetts*
9. Title 5 rOfficial Inspection -170 r
Subsurface Sewage Disposal'System,Form-Not for Voluntary.Assessments
�M �r 417 Commerce Road, Barnstable
Property Address
Laura F. Ware-McGouqy,
Owner Owner's Name --
information is 25 Cam Ion Road,Yarmouth Port MA 02675' June 4, 2009
required for every P `
page. CityfTown - State Zip Code.- Date of Inspection
D. System Information (cont.)
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:
F N/A
.
Type:
_ 1-5.5'x6'pit i
® leachuig pits number. w/4'stone. '
Teaching chambers number.
EJ leaching galleries.. -number
leaching trenches number; length: -
❑ leaching fields number, dimensions: --
[] overflow cesspool 4 number'. .
innovative/alternative'system
Type/name.of technology`
F Comments (note condition of Soil,'signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation; etc.)` z
Soil was sandy. Leach pit was found dry on inspection with a visible stain line approx. 6"from the
bottom. Leach pit was clean with:no evidence of hydraulic fail_ure,or problems in,the past found at the
time of inspection. Note: No laundr oon_system at this time. r '
417 Commerce Road Barnstable•03/08 Title 5 Official lnspectionform:Subsurface Sewage Disposal System-,Page 12 015 *'
Commonwealth of.Massachusetts
f Title 5 ® ivial. Inspection Form
Subsurface Selvage Disposal System Form.-Not for Voluntary Assessments
°M 417 Commerce Road, Barnstable
V Property Address— "
Laura F. Ware-McGourty `
Owner Owner's Name
information is 25 Campion Road, Yarmouth Port MA 02675' June 4 2009
required for every --- -
page. CityTFown 'State Zip Code Date of Inspection Y
D. System Information, (cont)
' 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 solidslayer N/A
N/A
Depth of scum layer
Dimensions of,cesspool 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);'
t
Materials.of construction: NIA
Dimensions _ N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure'; level,of ponding,condition of vegetation,
etc.):
N/A
417 commerce Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:Pe 13 of 15
3�
Commonwealth of Massachusetts
Title 5 Official Inspection Fortin
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.N 417 Commerce Road, Barnstable
Property Address
Laura F. Ware-M_cGourty w
Owner Owner's Name
information is required for every 25 Campion Road, Yarmouth Port MA 02675 June 4„2009 '
-
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of SewageDisposal System: Provide a sketch of the sewage disposal system.including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
' S13
r
,� - I 33
r L 33
417 Commerce Road,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 of 15
a
Commonwealth,of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System,Form Not for Voluntary.Assessments'
M s 417 Commerce Road, Barnstable K
Property Address
Laura F. Ware-McGourty
Owner Owners Name
information is 25 Campion Road, Yarmouth Port MA, 02675 June 4, 2009
required for every P
page. CityrFown - State Zip Code Date of Inspection
D. System Information (cont)
Site Exam:
Check Slope
❑ Surface
® Check cellar
El ,Shallow wells
18'Estimated depth to high ground water: +
feeeet
Please indicate all methods.used to determine the high ground water elevation:
Obtained from system design plans on record
j If checked, date of design plan reviewed: Date
Observed site(abutting hole within 150 feet of SA
S)
Checked with local Board of Health explain:
❑ Checked with local excavators,installers-(attach documentation)
® Accessed USGS database -explain:
AIW 247 Zone B 22.6' 1.9' adjustment
You must describe how you established the high ground water elevation:
Y Soil was sandy. Hand augered 4' below bottom of leaching with no water found at 1,3.0'. Groundwater
t adjustment in area at the time of inspection was 1.9' Bottom of leaching at 9.0'was found not to be
Iodated in the high groundwater elevation at the time of inspection. USGS map showed groundwater
to be approx. 18.6' below grade_
417 Commerce Road,Barnstable.03/08 — Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
417 Commerce Road
LOT 'NO. : ADDRESS: Barnstable, Ma.
014NERS NAME• Quentin R. Munson
SEWAGE PERMIT NO. 92-470 NEW: REPAIR: x
DATE ISSUED: DATE. INSTALLED:10-07-92
LNSTALLERS NAME : Cash's Trucking, Inc.
1,000 gal. holding tank. 1,000 gal.
INSTALLATIO►I OF: leaching pit/4' stone packing.
WATER TABLE: FINAL INSPECTION BY:
DRAWING OF INSTALLATION ON REVERSE SIDE:
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;1
M
A,
ea
N - TOWN OF BARNSTABLE 0
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT 3/7-62.6
INSTALLER'S NAME & PHONE NO. C�,p„ -•L
SEPTIC TANK CAPACITY I �jp
LEACHING FACILITY:(type) (size) 160e
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER tP.S1
DATE PERMIT ISSUED:
0
DATE COMPLIANCE ISSUED: /`G ' 77 �-
VARIANCE GRANTED: Yes No �(/
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� '�'•-<.
may® �
� 1
�& �/.
1
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Bi"aaal Workii Tnnitrnrtiun rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
417 Commerce Road, Barnstable, Ma.
................__...................-• ................................................ --------.....------------------............------•---------------....-----------......-----.------
Location-Address or Lot No.
Quentin R. Munson
......................_.......................................................................... ............................................. ------------------------
*-----------------------
Owner
W Cashes Trucking, Inc. Address
' ..-•.................................•------•--.......-•----•-----------.......................... •---------•--•------...............-----•------••------.................---=•••-.................
Installer Address
Type of Building 3 Size Lot--_--------_-------------Sq. feet
Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type,of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures --------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.............--. Depth................
xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................:sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------------------------------------•-----------•----•------------------. Date........................................
14
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
GT4 Test Pit No. 2................minutes per inch Depth of Test Pit...:................ Depth to ground water........................
P4 --------•-----------------------•---•---------------------------•---------.......------....--.-•--••.........................................................
0 Description of Soil............................................................................... --------------------•-•---------------------••-----....................................
x
U -----------------------••---------------••---------••-•------•------------------•--------.....--------.......------------------------•-------•---...................................................
W
x ------------------------------------------------------------------- -•--------------------•------------------------------------------------------------------ .................--------
U Nature of Repairs or Alterations—Answer when applicable..install--- ,000__gal. holdinq__-ar)k,_Before----
installing- 11000 gal. leachin jDit/4' stone packing I will remove all subsoil/clay from
t is are - ----------
greemenf
perlriiLer set his leach pi & backfilT with sand only
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance issued by the board o ealth.
Signed 09-18-92
Date
Application Approved B ------------------------------------- ------------ ---- �.
Date
. Application Disapproved for the following reasons: ........................ ...... .... ........................... .. ............................................----------
------------------------------------- ------------- - - ------------------ -------- -- ----------- ---- ------------------ --------------------------------------- - -- -------------- ...........................--------- -
Date
PermitNo. a-.......Y;7?......................... Issued .----------------------------- ----------------------...------
Date
4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratilan for Disposal l Varkii Tonstrurtion Frrmit {
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at: w
417 Commerce Road, Barnstable, Ma.
...•-- ----------•-•- - ._... ......................_............................
..._..._.....--..._._......_..__.
Location-Address or Lot No.
Quentin R. Munson
................... _-- ----- •-- .............................................. -----------------------------------------•-----------•----------------------------
w Cash's Trucking, Innc.er Address
Installer Address
d Type of Building Size Lot----------------------------Sq. feet f'
Dwelling—No. of Bedrooms._.____3...................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of ersons___________________________• Showers
� YP g ---------------•------------ P ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------.-------------•--•------------•--•-----•-----------------•---------------•----------...------•--
w Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity............gallons Length................. Width................ Diameter................ Depth__-___________-_
x Disposal Trench—No,-------------------- Width.................... Total Length.................... Total leaching area_..-----------------sq. ft.
Seepage Pit No---------------- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
►� Percolation Test Results Performed by-------------- --------------------------------------------------------- Date----------------------------------------
1.4
MTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---_•--____-___-_-_--__.
fro Test Pit No. 2----------------minutes per inch Depth of Test Pit___.---_____________ Depth to ground water........................
a ---•-------••----•--------------•---•----------•----------•------------...----------......_......--------------------------------._....---•------------_...--
ODescription of Soil.................`------------------...----....---.....---------------•--•--------------------------------------------------------------------------------------------
x
w
U Nature of Repairs or Alterations—Answer when applicable_install 1,000-_gal.__-holdzna__tank_Before
installinq�1,000 qal. leaching pit/4' stone packing_I will remove all subsoil/clay from
t:h%s area LIUa permiterj set this leach pit & bacKf1!1 with sand only. - ---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has-been issued by the board of"health.
Signed_.. -� < t.!l�( - J" � l/ 09-18792
------ --- --------------- -----------------
Dale
Application Approved By v - - - � q.
5
-------------------------------------------------------------------
Dare
Application Disapproved for the following reasons- ------------- .................................------ ------------------------------------------------
-------------------t------------------------------------------.--- -----------------.....---------...------------.---------------------------.............---------- --------------------------- ----------------- -------------------
Dare
PermitNo. ----� - -'....L.71A...-------------------- - Issued ----------------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifira#e of (foutylinure
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X )
bC ......................................sh's Tucking, Inc. [Ensign S. Cash]
Y
-----------------------------------------------------------------------------------------------------------------------
Installer
at . -----------------------------------------------------------------------------------
417 Commerce Road, Barnstable, Ma. [Quentin R. Munson]
------------------------------------------------------------------------------------------------- ----------................
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. ___.__.__9' ._-_..y_2. ...... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------- .. ......-..- .�- Inspector
-a-L---------•- -------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
9�_ TOWN OF BARNSTABLE
FiNo.. ..................• � .... .....---
OWposal Workii Tons#ruc#ilan' rrmif POBox 7
Permission is hereby granted__- Cash's Trucking, Inc. [Ensign 5. Cash] Yarmouthport, Ma.
to Construct(�) or Repair (X ) an Individual Sewage Disposal System 02675
417 Commerce Road, Barnstable, Ma. Quentin.R.-_hMunson]----------------------------------------------_-
street tt��
as shown on the application for Disposal Works Construction Permit No��•_=_/Id. Dated--',?_---
�•----------------------- (� Board -- Health
DATE........................ =-----
FORM 36508 HOBBS @ WARREN.INC.,PUBLISHERS