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HomeMy WebLinkAbout0014 DEACON COURT - Health ;deacon Cd`lert ° ' 41" I arnstalble 0 i Jown of Barnstable' # . Barnscabie - Regulatory Services Department &ARN rM MAM 639 Public Health Division ♦� 200 Main Street, Hyannis MA 02601r 2007 Office: 508-862-4644 ! Richard V. $cali,Director FAX: 508-790-6304 Thomas A.McKean,CHO. IF CERTIFIED MAIL # 7015 1730 0001 4990 4858 May 26, 2016 Connie Fazio a FR _ J, 14 Deacon Court Barnstable,MA 02668 ORDER TO COMPLY WITH ENVIRONMENTAL COD - E, TITLE'5 The septic"system located at.14 Deacon Court, MA was,last.inspected on .5/12/2016 by Michael DiBuono,a certified Title V Septic Inspectorafor the State of Massachusetts: j The inspection of the septic system showed that the system "Conditionally - Passes" under the guidelines of the 1995.TITLE 5 (310 CMR 15.00) due to the following: e Distribution-Box needs'to be replaced., You are ordered`-to;repair or.replace the septic system within one (1) year from f the date you receive`this notification:" Failure to repair/replace the•septic system with in,the deadline period will result in future"enforcement action: , PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S.'CHO >c-' Agent of.the Board of Health2113 . Q:\SEPTIC\Conditionally Passes Ltr\14 Deacon Court Barns May 2016.doc t v "R Tows of Barnstable. + RAMnABLE + MAS& Regulatory Services Department �fD Public Health Division 4 ' 200 Main Street, Hyannis MA 02601 . Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 . -Rev. 5/11/16• DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V:-310 CMR 15.000) An"x"marked in the ci is the failure criteria and associated repair deadline y -60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground Y ❑ Pumping more=than 4 times during the last year not due to clogged orfobstructed, pipe. Y ❑ Backup"of sewage into the h6use`due to an overloaded or clogged SAS o`r'cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet mvert due to an'overloaded or". clogged SAS or cesspool . `Y ❑ Any portion of.the SAS, cesspool;or,privy below high,groundwater elevation - ❑ Any portion of the cesspool within a Zone,I-to a public well , ❑ Any portion'of a cesspool within 50 feet'of a private water supply,well,with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). s 1. ` ' TWO (2)YEAR DEADLINE.CRITERIA ❑ Single Cesspool ' ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation ,of a driveway due to 14-10 components, etc) ❑ Leaching.pit or cesspool with high liquid level, <12" below.inlet(per,Town Code -§360-?q) f ❑ Leaching facility with standing liquid level at.or above the invert pipe (per Town. 'Code §360720 h) Repair deadline: WSEPT0DEADLINES TO REPAIR FAIIID SYSTEMS.doc Commonwealth of Massachusetts ��P050Z W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments f 1. 14 Deacon Ct Property Address Connie'Fazio Owner Owner's Name information is Barnstable Ma 02668 5/12/16 required for every / page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Im octant:When filling out forms A. General Information d'/# on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 8 Johns path Company Address S Yarmouth Ma 02664 Cityrrown State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the-Local Ap roving Authority 5/19/1.6 f spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****.This report only describesconditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17. �O r Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 � t , A Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. CityfTown State, Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms�not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cost.): ❑ Observation of sewage backup or break out or high static water level,in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑. ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Dbox is rotted'and in need of replacement. The system required pumping more than 4 times a year due to broken or obstructed pipe(s). Th ❑ Y q P p 9 Y o c P pe(s) e system will pass inspection if(with approval of the Board of Health): El broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further.Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or'a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Deacon Ct Property Address Connie Fazio Owner . Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than.100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 _ page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No` ❑ ® Required pumping more than 4 times in the last year`NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion*of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ E Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- El ® 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must.serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the,following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet'of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 11 El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply'well If you have answered "yes"to any question in Section E the system is considered a significant threat, .or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The'system owner should contact the appropriate regional office of the Department. t5ins•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is Barnstable Ma 02668 5/12/16 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System is in good working order. Dbox is rotted and has roots inside. Dbox needs to be replaced. Number of current residents: 1 Does residence have a garbage grinder? El Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water,meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date 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 Industrial waste holding tank present? ❑ Yes ,❑ No Non-sanitary waste discharged to the'Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Deacon Ct ' Property Address Connie Fazio Owner Owner's Name information is Barnstable Ma 02668 5/12/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Occupied Date Other(describe below): General Information Pumping Records: Source of information: None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: galloris How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other,(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts 4 Title 5 official Inspection D°orrn Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1984 r h rrivin h i Y No Were sewage odors detected when a at the site? es 9 9 ❑ Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ® cast iron ® 40 PVC ❑ other.(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented through the roof Septic Tank(locate on site plan): Depth below grade: 3.5 .feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 . P . If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '( 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 311 Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 " Commonwealth of Massachusetts w - Title 5 Official Inspection Form. Subsurface Sewage_Disposal System Form -Not for Voluntary Assessments wM 14 Deacon Ct SV Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont. Comments (on pumping rep mendations, inlet and outlet tee or baffle condition, structural integrity, liqui Levels as related t utlet invert, evidence of leakage, etc.): Tees are ce a evels are normal. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):- Depth below grade: Material of construction: El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarrrl.in working order: ❑ Yes ❑ No Date of last um in p p g Date Comments (condition,of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Citylrown State Zip Code Date of Inspection D. .System Information (cont.) s Distribution Box (if present must be opened) (locate on site plan): . Depth of liquid level above outlet invert Dbox is rotted and in need of replacement. 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.): Pump Chamber(locate on site plan):' Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code_ Date of Inspection D. System Information (cont.) Type- ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts r - Title 5 Official Inspection Fora A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Formk Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately f t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17' Commonwealth of Massachusetts W Title 5 Official Inspection Form u Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft 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 describe how you established the high ground water elevation: Usgs maps indicate NGW at 10+ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 5/24/,2016 Assessing As-Built Cards i Page l0 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION(continued} . Ist9Address: rot$ Owner. _� b Date of inspetYloa b =TCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system inclutiing ties to at least two bet�mlrs•Locate all wells within 100 feet Locate where public water P reference landmarks or supply enters the building. rn . http:/Avww.townc,founstable.us/AssessingtHMdisplay.asp?fnappar=300052&seq=1 1/2 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Deacon Ct Property Address Connie Fazio Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑, Inspection Summary: A, B, C, D, or E checked' ❑, Inspection Summary D (System Failure Criteria Applicable to All Systems) completed El System Information- Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 117 of 17 `gyp IKE Town of Barnstable Public Health Division ` MRNSTA LE, ` 200 Main Street ' Hyannis,MA 02601 If Connie Fazio 14 Deacon Court Barnstable, MA 02668 � 1 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid I USPS I Permit No.G-10 I I I I • Sender: Please print your name, address, and ZIP+4®in this box• I I I I I I I I I I I I I I I I � I I USPS TRACKING# I I I I I I I I I I 9590 9403 0521 5173 2828 07 i a Ae 1 o Complete items 1,2,and 3. A. Signature I is Print your name and address on the reverse X ❑Agent 1 so that we can return the card to you. ❑Addressee I 13 Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery I or on the front if space permits. I 1. Article Addressed to: D. Is delivery address different from item 11 ❑Yes ! I If YES,enter delivery address below: ❑No I I I I 1 3. Service Type ❑Priority Mail Express® II I�III�I III ICI I I I I I II I III I II II I II I I I I II III 0 Adult❑Adult Signature Restricted Delivery Registered istered Mail Re tri t 1 9 ry ❑Registered s c ed 9590 9403 0521 5173 2828 07 ❑Certified Mail® Delivery ❑Certified Mail Restricted Delivery ❑Return Receipt for ❑Collect on Delivery Merchandise 2. 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Er Ir 0 Extra Services&Fees(check box,add fee as appropriate) ❑Return Receipt(hardcopy) $ • ftN6. ❑Return Receipt(electronic) $ Postmark C O O � t7 O ❑Certified Mail Restricted Delivery $ Here O ❑Adult Signature Required $ w ❑Adult Signature Restricted Delivery$ L O O O Postage m m �m N ® Total ~ l Postage and Fees r=1 r 9 ,rq $ Ln U l ul Sent To ra O `O I Q .------ ------------------------------------------- f%- Y I`- Sf�eet and Apt.No.,or PO Boz No `{ga '� • Ctry:State.ZIP+48-•-------•------------••-- Pi f �, T Certified Mail service provides the following benefits: ! ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,presets this. delivery. USPS®-postmarked Certified Mail receipt to the, x.... g, ■A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service' -Restricted delivery service,Which provides for a specified period. delivery to the addressee specified by name,or P P to the addressee's authorized agent. i� .7j Important Reminders: -Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not as s;s First-Class Mail®,First-Class Package Service®, ff 9 available at retail).or Priority Mail®service. -Adult signature restricted delivery service,which ■Certffied Mail service is notavailable for requires the signee to be at least 21 years of age, international mail. and provides delivery to the addressee specified ■Insurance coverage is a doesnotavallablec for purchase by name,or to the addressee's authorized agent z with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically inducted with accepted as legal proof of mailing,R should bear a;� a ,,,"+'�"'�"`; ;"?^� t certain Priority Mail items. USPS postmark.If you would like a postmark on f, ■For an additional fee,and with a proper this Certified Mail receipt,please present your I s. - �- endorsemerrt on the mail piece,you may request P Y Y q Certified Mail item at a Post Office"'for �... .q,........,�....,.,.... ;: the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion j I .4 + of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply _ F" You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. ;}fix.^� f electronic version.For a hardcopy return receipt, f, „ complete PS Form 3811,Domestic Return Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records. ! Ps Form 3800,Apdi 2015(Reverse)PSN 7530-02.000-ee47 No.;�9 I&s 1 —7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes fipfication for Misposaf *pstrm Construction permit Application for a Permit to Construct( ) Repair C/4 Upgrade( ) Abandon( ) ❑Complete System individual Components Location Address or L N /�, Z)C-,4CG_ C+e* Owner's Name,Address,and Tel.No.&J"A / �E'Ga ' Assessor's Map/Parcel i f*r�' � �* U N C��� !� Installler's ►Ja/ Name,Addr ss,and Tel.N�.�.�y1 t 3GY 4S�7 Designer's Name,Address,and Tel.No. �j I�iJ�n tl� s lanJ �� �'L/�E�(/ii✓l'f+l. � �r,"!�S -1 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 9 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. L ce-r- `�— Description of Soil Nature of Repairs or Alter °p Alterations(Answer when applicable) G fl�4' C � � ,S j'/i ✓-�'��o� Jam,� Date last inspected: '`b Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ¢— gne _ Date J Application Approved by Date Application Disapproved Date for the following reasons Permit No. `. Date Issued --,-" C ,j . r. No.1W � ' �� Fee THE COMMONWEALTH OF MASSACHUSETTS- Entered in computer: Yes y - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS Rpplitation for Disposal *pstrm Construction Permit t Application for a Permit to Construct( ) Repair 90 Upgrade( ) Abandon( ) ❑Complete System individual Components Location Address or , t3 �s1-SLR or� Owner's Name,Address,and Tel.NJJo.E`r, n"t Assessor's Map/Parcel0e&,po, el1 nstaaa er's Name,Address,and Tel. o. ! �6�' I..S5r\ "7 °7 Designer's Name,Address,and Tel.No. !•J fn O�^U 5 LuJ C/ %-iE �14t't CJ ✓(IN S P.y=p /t- Type of Building: f Dwelling No.of Bedrooms 1!'� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) E� Other Fixtures Design Flow(min.required) /f�/� gpd Design flow provided gpd r Plan Date Number of sheets Revision Date Titles Size of Septic Tank Type of S A.S. cei)c4 F- Description of Soil : Nature of Repairs or Alterations(Answer when applicable) JeC• 12r'4 C' V ;5 f-/! Lk 4/0c,- /-2,O A { of - Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and etro__place the system in operation until a Certificate of Compliance has been issued by this Board of Health. C, ign / Date 7 �� Application Approved b T Date Application Disapproved) Date r for the following reasons . . Permit No. �� / ,! Date Issued /6 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CE(RTTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(04-) Upgraded( ) Abandoned( )by s Se K. -cf 6 ,,,Z. at I L� jj��c,-CG yi. e-#Ce` has-been constructed in accordance - with the provisions of Title 5 and the for Disposal System Construction Permit NQ f17—M dated Installer D i/g L4 0+1 Ca O C v�-'� n/- f)leq Designer #bedroomsA) Approved design flow ^ A1 gpd The issuance of this pe t shall not be construed as a guarantee that the system will ftKFubp ,,,�yass designed. i Date / . �& inspector (,� ------- =� ------=------ --- - = == -- - -------------------- ------------------------------{----------------------- No7_Z/6 1'73 Feb THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(W Upgrade( ) Abandon( ) System located at /y DcA.f Da �/E� W /3 ez,,,7 S hC,l'le and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe t. y Date j�� 1 Approved b AsBuilt Page l of 1 Page l o of]1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E T PART C SYSTEM INFORMATION(continued) , Property Address: � s Gc Owner. Date of on: inspectl b . SXZTCH OF SEWAGE DISPOSAL SYSTEM F Provide a sketch of the sewage disposal System including ties to at least two reference 1 permane� andrsarks or marks.Locate all wells within 100 feet Locate where public water supply enters the building. ` + J . .• r . . '� tea• http://issgl2/intranet/propdata/prebuilt.aspx?mappar=300052&seq=1 5/25/2016 Commonwealth of Massachusetts Title 5 Official Inspection Forte. Subsurface Sewage Disposal System Form-Notfor Voluntary-Assessments 14,Deacon Court y PropertyAddress Domenic Fazio Owner Owner's Name: information is required for every Barnstable MA 02630 ^03/17./1'2' t' page. City/Town `State ZipCode Cate of Inspection -inspection results must be submitted on this form.Inspection forms may not be agtered in any way.,:Please see,completeness checkliist.at_the end,of the'"form.. Important:When A. General' Information,filling out forms _ on the corn uter, t --4 P �. use only the tab 1. inspector. ( r.a *ey:tomove your cursor-do not Michael'Kellett F M ruse the return key. Name of Inspector b ;t Aardvark.Environmental Inspections- ' ry Company Name PO:box 896 'Company-Rddress East Dennis 'AAA 02641 CD City/Town State: Zip t .—. On 508-385-7608 SI 3742 Telephone`Number Ucense Number F B. Certification f I certify that 1,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.tam a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: . ® Passes ❑ Conditionally Passes- ET Fails ❑ ;deeds 1=udher,'Evaluation by'the.Local Approving Authority •G'�.�( 03/1'9/12`. J i Inspector's Signature Dater The system inspector shall submit az copy of this inspection:report tothe Approving.Authority(Board of Health,or DEP)within Wdays of completing:this'inspection-If tfie system is,a shared system or has a Resign flow of 10 000 gpd;or greater,the inspector-and+the system owner shall submit the report to the;appropriate:regional-office eofthe,DEP.The original should be sent to the system owner and copies:sent to ithe'buyer,if applicable,,and.the approving<authority-r. ****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 wilt perform it the future under the:same ordifferent conditions of use. t5ins•11/10 Tile'5 Offcial lnspedion' b.,urface 5ewage,Disl al System•Page 1 of 17 Commonwealth of Massachusetts Title 5 �3fficia: 1nspection Form s, Subsu:cface Sewage Disposal System farm jNotfor VoluntaTy Assessments z '14 Deacon Court Property Address Domenic Fazio Owner Owner's•:Name _. • a information is Barnstable .•_y MA 02630.' `03/1'711Z, required for every - page. 'City/Town 4 'State Zip Code Date of Inspection B. Certification (cont) Inspection Summary:Check. A,B,C D-or E/afways;complete-all of'Section D> A): System Passes. w ® I have not found-any information which in that iany of the'failure criteria described in 310 CMR'15,303 or4n 310` IMR 15.:304 exist.Any failure criteria not evaluated are indicated;below. , Comments: B) System-Conditionally Passes: -one lor more system-components-as 4escribed jin-the"Co:ndikional'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_. ` x } Check the box.for"yes"' "no""or"not determined"°(Y,N; ND)':forthe.followmg:;statemenis.If"riot. , determined,"please explain- The septic tank;is metal and-over years old*orthe septic tank!(whether metal or not)is structurally unsound,Exhibits stabstantial in`filtration or,exfltration or<tank'failure lis 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 wilt 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.. 0.Y N -N'D(Exp ain below): .L t5ins-11110 Title 5 0fticiaUnspection form:Subsmface:Sewage Disposal System-Page 2 of 17 Commonwealth,of Massachusetts: ,. Title 5 Official Inspect Ion, Form,, Subsurface'Sewage Disposa'I System:Foam-Not for Voluntary Assessments 14:Deacon Court 'Property Address Domenic Fazio Owner Owner's Name information is required for every Barnstable MA 02630 03/17/12 page. City/Town 'State -Zip Code - Date of'Inspection B. Certification (cone.) B) Systemm,Conditionally:Passes=(cont:): A ❑ Observation:of sewage backup:orbreak out:or high static,water,level in the-distribution box due to broken or obstructed;p.ipe(s)or due to a broken,settled•or uneven distribution box.System will pass inspection if{with,approval 6f',Board of Health): ❑ broken;pipe(s);are replaced, ❑ Y " ❑ 'N' [] ND(Explain below): ❑ obstruc tion is removed" ❑•Y ❑; N: ❑. ND-(Explain'below)_ ' r ❑ distribution:box is leveled:or,replaced ❑; Y ❑` N ❑ ND(Explain:below): ❑ The system required;pum.ping more than 4'times a year due to broken lor obstructed'pipe(s).The system will pass inspection if(with approval1of the Board,of!Health ❑ broken:pipe(s):are:replaced ❑ Y ❑ ,N ❑ ND.(Explain below): ❑ obstruction.,isi removed: ❑ Y', ❑:: N= ❑` ND. (Explain:belowr):':. • ' r C) Further Evaluation is,Required bythe Board of Health: ❑ Conditions exist whtch require furlherevaluation bythe Board,of Health in order to determine if the systein.is`failing'to?,protect�public!health,safetyior the+environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1')(b)that.the.system is not-'functioning.in;aimannerwhich:.wilt protect,publiehealth; _ safety and the environment ❑ Cesspool or privy is within.50.feet.of a surface.water Cesspool or i privy is within:50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5i Official.Inspection Form:Subsurface Sewage:Disposal System Page 3 of 17 Commonwealth:of Massachusetts; H Title 5 Officiat inspectioFn Form -Subsurface Sewage!Disposa I System:Form-Not for Voluntary Assessments 14 Deacon Court 'Property Address Domenic Fazio " Owner Owner's Name information is Barnstable MA 02630 03/1.7/1'2: '{ } required for every page. City/Town 'State ' ip,Code Date of 21 nspection B. Certification (cont.) t 2.. System,wifffail:unless.the:Board,of Health'{and,Public Water-Suppher.if`any) determines that the system.,is functioning;in&mannerthat protects the public health, safety and environment,, ❑ The system has a septic tank and soil absorption system{SAS)'and the SAS is within 100 feet of a surface'water supply or tributary to a surface'water supply. ❑ The system has.a septic tank and'SAS.and the SAS+is within a Zone 1 of a public water supply. ❑ The system has a septic tank.ands SAS and!the,SAS is within.50 feet.of a..private:water supply well. ❑ The system has aseptic tank and SAS and the SAS is less than 100 feet;but 5(Y feet or , more from a private water 1supply well".. Method used:to determine distance: Thin 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'ofthe analysis must be attached to this form_ 3. Other: D) System Failure Criteria Applicable to Alf Systems.; You must.indicate"Yes"or"No"to each of the:Mlowingi for all:inspections; Yes No ❑ ` 'Backup of Sewage into facility orsysterri`component due to overloaded or clogged SAS or cesspool. ❑, ® Discharge:orpondingof effluent to the,surface of the ground:or,surface waters due to an,overloaded or clogged;SAS.or cesspool: ❑ ® Static liquid level in the distribution,box above outlet invert due to>an:overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is Tess than 6"be.low invert or availabie volume is less than '/day flow t5ins-1 Ill 0 'Title 5'OfficiaUnspection,Form:Subsurface Sewage Oisposel System-Page 4 of 17 w ' Commonwealth,of. Massachusetts., w ; Title 5ffciat tnspeCtion Form Subsurface Sewage:Disposal System Forn-Not for Voluntary:Assessments 14 Deacon Court Property'Address Domenic Fazio Owner Owner's Name a information is required for every Barnstable MA 02630 03/17/12 page. Citylrown State .Zip Code Date of inspection B. Certification (cone.) . Yes No Required pumping:more.than:4 times:in:the�lastyear NOT due to clogged or ® obstructed pipe(s).,Number of times-pumped: ❑ 0 Any portion ofthe'SAS,cesspool orpnvy is below`�high;ground water elevation. Any.portion ofcesspool_orprivyis within 100 feet of surface water supply or tributa to a surface water supply. PP Y ❑ Any portion of&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. . . ❑ S Any portion<of.a cesspool or privy is lessthan'l00 feet but greater than 50 feet from a private watersupply well with no acceptable water quality analysis. [This system passes if the well water:anailysis,performed at a DEP certified laboratory,;for,fecatcoliform:bacteria:indicates absent and the presence of ammonia�nitrogen and nitrate nitrogen is equal to or less:than 6 ppm, provided that no other failure criteria are triggered.-A.copy of the analysis and chain of custody must be:attached to-this form.] M ❑ The system is a�cesspo£ol serving a facility with;a design flow of ZOOOgpd- 1'0,000gpd. ❑ The,system fails.a+have determined that one orm ore of the above failure criteria emst 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-correctthe failure.. E) Large Systems 'To be considered a large.system'thesystem must serve a facility with a design flow of 1>0.000;g to 1s 000 gpd. ' For'large systems,you pust.indicate either"yes"or"`no"to each of.the following,.in addition to.the j questions in Sectionl?. Yes No• ❑ `'.❑ the_system pis within 400 feet of a surface drinking water supply ❑ -.Cl the system:is withim'200 feet of a tributary to a.surface drinking water supply 4 the:system is�located in a:nitrogen sensitive area;(Interim-Wellh.ead Protection ' ❑ Area-NVPA,or a mapped Zone 11 of a public.water supplywell+ 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 underSecton D shall upgrade the system;in accordance with 310 CMR 1�5.304.The system owner should contact the appropriate regional office,of the'Department. t5ins•11/10 Title 5 Official Inspection.Form:Subsurface,Sewage:DisposafSystem;-Page 5 of 17 Commonwealth,of Massachusetts Title 5 O iciat inspection Form Subsurface Sewage Disposal-System Form-INot:for Voluntary Assessm ents `14'Deacon,Court Property Address Domenic Fazio Owner Owner's Name information is Barnstable MA 02630,� 03KWI required for every _ page. City/Pown a `State Zip'Code Date of lnspection ,C. Checklist Check if the.following have been done.You:must indicate."yes°ou"no"as;to,each of the:following: Yes No ® ❑ humping information was provided by the owner,�occupant;or Board of Health ❑ 'N Were:anyof the-system:components;pumped out in the previous two weeks?- ® ❑ Has the system received norma[Rows.is the previous two.week period? ❑ ®. Have large:volumes ofwater been:introducedto thesystehT recently or as'part of this inspection? ® ❑ 'Were:as built plans�ofthe system obtained,and examined?(if they were not available:note,as N/A) ® El thefacility.ordwelling.inspected forsigns:ofsewage;bac.k+up? ® ❑' Wasthesiteinspected'!for'signsofbreak�dut? r ® ❑ Were all systeml corr►ponents,excluding;the SAS;,located on site?` ® ❑ 'Were_the°septic tank manholes uncovered,opened,and the interior of the tank <<ins:pected for the condition of the ba#fles<or tees,material of construction, dimensions, dep'.th of liquid,depot of sludge-,and,depth, of scum? ® ❑ Was the facility,owner(and occupants d different Romowner.},provided with information on the proper maintenance:of subsurface sewage disposal.systems? The size and:location,of the Soil!Absorption Systenr(SAS).,on,the site has been determed•based on- 0 ❑ Existing information.._,For example,:a:plan;at the Board of Health. L ;❑ 'Determined in the field(if,any of.the failure criteria:related to Part C is at issue approximation:of distance is unacceptable)[31 OF,CMR:1f5 302(5)],' ' D. System Information Residential'�Flow�C,onditions: 'p Number of bedrooms(design;):. 4 Number of bedrooms(actual):' 4 DESIGN flow based on 310 CMR 15.203(for example 110 gpd'x#of;bedrooms): 440' t5ins-11/10 TNe5`Offitial Inspection Forn,Subsurface•'Sewage-Disposal System-Page 6 of 17 • k Commonwealth of Massachusetts. Title �3fficla inspectioln Form . Subsurface Sewage Disposal'System Fo;mi iNot,for Voluntary Assessments 14 Deacon Court Property Address Domenic Fazio' ' Owner Owner's Name information is ' required for every Barnstable MA 0263a, 03/17/1!2' page. City/Town `State Zip Code: Date of Inspection D. 'System Information . Description:. Numberof<currentaesidents: Does residence have a,garbage grinder?'' Ej Yes ED. No Is laundry on a separate sewage:system?[if yes'separater inspection:required]: 0: Yes Z No Laundry system:inspected ;' - • �,Yes"� No Seasonaluse? Yes ® No Water meter readings,if available(last 2`years usage-(gpd)): Detail: Sump pump? i Yes ® No , Last date of occupancy:. '{ current: Date CommerctaMndustriat Flow Conditions: , Type of Establishment: _ r Design flow(based on 31U CMR 15.203): Gallons perdar(9Pd) • e - Basis of design il;w(seats/persons/sq.ft,,etc:.),:: Grease trap present? • E Yes [I No r Industtiaiwaste�holding tank present? Q Yes ❑ No Non-sanitary waste discharged to the,Tide 57system7 [: Yes ❑ No Water meter readings,:if available: t5ins•11/10 - Title 5Official Inspection,Form:Subsurface•Sewage,Disposal:Sysbam_-Page 7 of 17 Commonwealth of Massachusetts ` TIIe1C1l Inspection Qrt1 s Subsurface Sewage Dis,posa'I System•Fame-Notfo'r Voluntary Assessments r 14 Deacon Court :Property Address Domenic Fazio. OwnerOwner's Name , information is Barnstable MA -02630 . required for every �' ` 03/17/12: , page. ity/Town State Zip Cod_a Date of Inspection D. 'System Infor,mation (cunt.) Last date of occupancy/user Date Other(describe-below): Genial In.foirmation Pumping'Records: �} Source of-information: Was system pumped as part of the inspection?' ❑< Yes: '. No If yes,volume pumped: gallons. ; How was.quantity pumped:determined? Reason forpumping: Type of System: i ® Septia tank,_distribution box;sod absorption system f , ❑ Single cesspool ❑ -Overflow cesspool , rt. Privy ❑ Shared.system(yes or no)(if.yes,.attach previous inspection records,.if any) ❑ innovative/Alternative technology.-Attach a copyofthe current operation and -maintenance contract•(to,be obtained from system owner)and a copy of latest inspection of the VA system'by system;operator�under:contract ❑, 'Tight.tank.Attach:acopyof the DERapproval-' = ❑ Other(describe):: , t5ins-1I'M Title:5.Official;inspection Form::5ubsurface Sewage.Disposal System-Page 8 of 17 t ' W ; r . Commonweafth:of Massachusetts t - � Title 5 ffici-ail in edf�o�t F€�rr�-u Y Subsurface--Sewage:Disposal System aForin A-.Not:for Voluntary Assessments 14`:Deacon Court ,_ e Property'Address �. . Domenic Fazio Owner Owner's Name: information is r Barnstable MA: 62630' required for every page. City/Town ;State Zip Code Date of Jrtspeotion' System Information,,(coat. D. ) Approximate age,of WE components,'date installed(if"known.),arrd.,source of information: 11/1�5W per BOW Were sewage odors detected when arriving at-the site? 3, _Yes 'No Building:Sewer.(locate"on site plan). Depth below grade: ` .. feet." � Material of construction: ' El cast iron 40 PVC []other(expla#n) a Distanceftom,private watersupply well orsuction hne '"°.feet Tom: ti Comments on condition of joints ventin ,evidence of Ceaka , etc r • n e Septic_ Tank'(locate on site Depth below grad"e: • - ," A Material of construction. ®concrete Elmetal ✓'b . ,�{fiberglass ��polyetlaylene [�otiier(explain) rT 40 If tank`issmetal1#st ale s s} ears` Is age confirmed by a Certificate.of Compliance?(attach as copy:ofcerticate) Q Yes Qo Dimensions: y 1,000 gat TI.. Sludge depth: t5ins 11110 Met Official lnspeetion Form:subsurface Sewage:Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora 1.1 Subsurface Sewage'DisposalSystemForin NotforVolun:tafy:Assessments '14:Deacon Court Property Address Domenic Fazio p." Owner Owner's Name information is required for every Barnstable MA 02630 03/17/1'Z page. CityTrown State Zip Code Date of Inspection D. System lnformation .(coat!) `. Septic Tank:(cunt.) Distance from top of sludge to<bottom.ofoutiet.tee or baffle; 28" ,2" Scum thickness -.. 6" Distance from top of scum to top:of outlet:tee zrrbaffle Distance from bottom of scum to bottoms of outlet.tee-or baffle 1.5 How were dimensions determined? measured: Comments(on pumping'recommendations,inlet and,outlet tee orbaffle condition,structural integrity, liquid levels as•related-to outlet invert,evidence,of leakage,etc.): The tank was sound.and tight with:tees-in place arid liquid at outlet invert. Grease Trap(locate on site plan,),.- Depth below grade: feet Material of construction: Elconcrete 0,metal. 01fiberglass Flpolyethylene ❑ other(explain): Dimensions: Scum thickness Distance from,top of scum;to top;of outlet tee or'baffle: Distance from bottom of scum to bottom:of`outlet tee or baffle: ;Date of:last,pumping: Date t5ins-11l10 r Titlei5 Official llnspection Form:Subsurtace Sewage Disposal:System-•Page 10 of 17 P Commonwealths of'Massachusetts Title 5 Official Inspection Form Subsurface lsewage Disposal System:Fo.rm-:Not for Uoluntary,Assessmen'ts ti '14.Deacon Court ' Property Address r , Domenic Fazio Owner Ovrner's Name information is required for every Barnstable . . MA 02630 03/17112' page. Cityfrown 'State Zip Code Date of Inspection D.. S.Ystern Information (coat.) , Comments(on,pumping,recommendations,,inlet.and:outiettee or baffle condition,,,structural.integrity; liquid;levels as related:to outlet,invert'evidence of leakage;.etc.):: Tight or Holding Tank(tank must;be,pumped at time of,inspection)(locate:-on site plan): Depth below grade: Material of construction: f ❑ concrete 0;metal 'D fiberglass E polyethylene: El(other(explain): Dimensions.: r Capacity:' t gallons Design Flow` M gallons per day Alarm present € 0. Yes Q:` No- Alarm level: Alarm:in working order: Q-Yes ❑ No Date of last pumping:: . Date Comments(condition ofalarm andfloat witches,etc.)-, . t � • 1 *Attach copy of current pumpii g contract(required).,Is copy,attached? 0. Yes Q No t Ins•11/10 _ TrBe S.Official Inspection;Form:Subsurface Sewage;D*osai;Systemi•Page 11 of 17 Commonwealths of Massachusetts> Title 5 Official inspection Form a s, 'Subsurface:Sewage D.isposa9System Form-Not for Voluntary Assessments 14'Deacon Court s Property Address Domenic:Fazio Owner Owner's Name. information is required for every Barnstable MA 02630''- 03/1,7L1'2' page• Vty7Town State „Zip"Code Date of Inspection D. System Information (cone.) ' Distribution Box(if present must beopened):(locate on.site plan):: Depth of liquid,level above outlet invert:_ even Comments(note if box is level anddistribution;to outlets=equal,any,evidence of.soiids carryover,any evidence of leakage into or,out Hof box,<etc.): The box was level;and tight with no sign-of carryover. Pump Chamber(locate on site plan),: Pumps in working order:: ❑ Yes ❑ No ' - a Alarms-in working order: i ❑.Yes ❑ No Comments{note,condition.(Ovump�chamber,icondibon of pumps and appurtenances, etc.): 1 r "- rp Soil Absorption)System(SAS)(locate on site plan,excavation,not.required),-., If SAS not located,explain why:: ` f + t5ins-11/10 •• Title.5 OfficialInspectionfonn:subsurface Sewage"Disposal,Sy m, Page 12 or 17 i Commonwealth of Massachusetts r Taitte, 5 ff cash h is�pectI n For Su.bsu:fface Sewage Disposal System n,Form-Not for Voluntary Assessments ., '14 Deacon Court .. 4 w:Property Address -• , � - � •, . � . Domenic Fazio- Owner Owner's Name,. e information is ? z required for every Bamstable•, + # MA`F 02630: 03/1 page- city/Town 'State Zip Code, Date of Inspection r D. System .inf O'1'f9at10n Type. U leaching;pits- ' number.- , t • leachngchambers, number: ❑ ,leaching galleries R ;number Elleaching trenehes ritimter,lengitt a. ❑ leaching.fields'. _ number,,dimensions- ❑ ,overflow cesspool 'number: , ' ❑ •innovative/a`Itemative.system Type/nam.e°of technology., _ , 4 Comments(note condition of soil'i signs of hydraulic.failure,lever of,'ponding,,damp soil,condition of vegetation,etc.). a. W This system has ra6'x6'precast pit surrounded by,2' W stone.There was 30"of liquid in the pit. • w b , - Cesspoois;(cesspool.must_be pumped,as�part ofrinspection)(locate on site plan) „y. y , _ Number and conliiguration Y. ` _ •41 ; Depth—top. liquid!to inlet:invert r 6 • ft . kY , Depth of solids layer• K.. � - $" `�; �' a +n e r • r 'Depth:of scum layer v Dimensions of cesspool < 3. Materials of construction k Indication�ofgroundwatevinflow ❑` Yes - ❑ No t5ins•11/10 ' Tdle 5 Official,Inspection FormcSubsurrace Sewege:Disposal System•Page 13 of 17 _ h p Commonwealth,of Massachusetts. ' s pa :a Subsurface Sewage D.isposAl System Form.-Not for Voluntary Assessments} t F , 14 Deacon Court Property Address DomenicF�aZld' iF < 'k Owner Owners•Name zz , information is _ required for every Barnstable r a 02630<,'k • 03/17F.12 a page_ Gity/fown . +State Zip Code Date of inspection. D. System I nfo:rmation (corn )' Comments.(note condition:of soI,signs;of'hydraulic.failure,. evet of p9nding„'condrhon of vegetation, etc.): tx r, a.. :: '. ♦ F _..i V 4k f T ... s _ F,.: .4^h `..4 c y - , N Privy(locate oR site:plan,):_ .,. Materials of construction , y . Dimensions Depth of solids Comments(note condition of soil`,signs,of hydraulic failut'e,,.'levelzof liorjing,;condition of:vegetation, etc.)• - ' a . x n r a r_ v p - u , t C , ` c t5ins•Y1r10. - TTe 5 Official:Inspecbon iFonn::Subsurface Sewage'DisposaI. stem-Rage 14 of 17 commonweauh of Massachusetts - olpitle 5 Offlocial Inspection Subsu Lace Sewage:Disposal System Fown-.blot for Voluntary Assessments 14 Deacon Court Property Address Domenic Fazio p Owner owner's Name inf° is reqtdred or e ay Barnstable M/kti 02630 03/17112 page. City/Town hate Zip Code Date of Inspection D. System 8n 1 ta®n (cont.) Sketch Of Sewage Disposal System:.Provide a view of the sewage disposal:system,including ties to at least two permanent.reference landmarks or benchmarks'.Locate ad wells.within 1`0G feet.Locate where public.water supply enters the budding.Check one of.the boxes-below, ® hand-sketch the area below [� draw ng etlaached separately { a t5ins•1Vto• - TMe5Offichd uVacbmFartn:Subsurface Sewage0hpasal;Systarn Page15ot17 A= Commonwealth.of Massachusetts. Title 5 Officials Inspection Farr Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments 14 Deacon Court Property Address / Domenic Fazio r Owner Ownec's.Name information is Barnstable MA 02630' 03/1'7/1'2 required for every, page, 'CityTrown State Zip'Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ' ® Check cellar i ❑ Shallow wells Estimated depth to high ground water:: 8.4' feet Please indicate all methods,used;to determine the'hig'h groundwater elevation: ❑ Obtained from system design-planson record If checked:,date of design plan reviewed: Date ® Observed site(abutting,property/observation;hole within 150 feef;of SAS)` ❑ Checked with slocal Board of HeWth-explain: , ❑ Checked'with.-local excavators;installers (attach.documentation):, ElAccesse.d 11SGS database-.explain: You must describe:how you;established.the"high ground water elevation: , augered to11.0 feet and-found.no water. adjusted to,8.4 feet: ' Bottom of leaching is at:71,feet. • r • Sefore filing this Inspection Report,please see Report:Completeness Checklist on next page. t5ins•11/10 'Tttle5 Official inspection'Form:Subsurface:SewageDisposal System•Page 16 of 17 t Commonwealth of massachusett§ Title 5 OfficIA Inspection Form. Subsurface Sewage DisposatrSystem,Form--Not for Voluntary;Assessments. 14 Deacon Court Property Address -Domenic!'Fazio Owner Owners Name regtAr atone Barnstable MA 02630 03/17112 . required for-every - page. City/rown- state. Zip Code: Date of Inspection. E. Report.Completeness:Checklist . ® Inspection Summary:A,'B, Cy D,or E checked ® Inspection Summary D'(System Failure Criteria Applicable to All Systems)completed ® System information Estimated:depthi to�high groundwater ,. ® Sketch of Sewage Disposal System'either drawn on page 1,5 or attached ihlseparate fife. x r F4.. A, v. -,L r t5ins•11/10 {¢ Title5Official Inspection Form:Subsurface•SevoageDisposal'System-Page 17 of 17 .. ry HirGH GROUND-WATER LEVEL COMPUTATION Date: F Site Location:' I)eC 0 , Permit: Owner: Phone: Contractor: Phone: . Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. , F r Ut (depth is in feet below land surface) Date: 0 S' i7 1� below Is mm/dd/yy STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well F • . t W a B) Water-level range zone STEP 3 Using monthly "Current Water'Resources Conditions" determine current depth to water Dd ! level for index well. mm/YY STEEP-4 Using Table of Potential Water Level Rise for index well (STEP 2A), current depth to water level for index well{STEP 3), and water-level zone (STEP 2B).determine water-level 0 adjustment .; ST EP . Estimate depth to high,water by subtracting the,, 0 water-level adjustment (STEP 4) from measured depth to water ievei at site (STEP i). RRO'P� ' �lb8�s Sl- "Potekiai tv ter-Le4dl Rise- are a�cli� as unro llss ea �®i~r�ei�fie. r ecodcommissiori.org/welis.html monthly index well data: www.cap i Commonwealth of Massachusetts" Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. , 14 Deacons Court Property Address Domenic Fazio ' Owner Owner's Name information is gamstable MA 02630 08/02/08 required for State Zip Code Date of Inspection every page. -CitylTown---_ - Inspection results must be submitted on this form. Inspection forms may not be altered in any way, Important: A. General Information When filling out S I 135 forms on the computer,use 1. Inspector: _ only the tab key 3 O 6 0 S Z to move your Michael Kellett _ �� cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspqctions Company Name P.O. Box 896 Company Address East Dennis MA 02641 a�a Cityrrown State Zip Code 508-385-7608 S13742 l Telephone Number License Number • J I B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. f am a DEP approved system inspector,pursuant to Section 16.340 of, Title 5(310 CMR 15.000).The system ® Passes! ❑ Conditionally Passes ❑ ails ❑ Needs Further Evaluation by theLocal Approving Authority t: - F. Co- . 08/04/08 _> Inspector's Signature Date ; The system inspector shall submit a copy of this inspection report to the Ap'f :ving f thorito(Board' of Health or DEP)within 30 days of completing this inspection: If the system a shared system or has a design flow of 10,000 gpd or greater;the inspector and the system owner shall submit the report to the appropriate,regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if,applicable, and the approving authority. N ****This report only`describes conditions at the time of inspection and under the conditions of use p at that time.This inspection does not address how the system.will perform in the future under the same or different conditions of use. ff,, b4? ` Cf' Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewerage Disposal System Form-Not for Voluntary Assessments'. .. 14 Deacons Court Property Address � _ $ Domenic Fazio Owner Owner's Name information is Barnstable MA 02630 08/02/08y required for — , every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) r Inspection Summary:.Check A,B,C,D or E`I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described' in 310 CMR 15.303 or in 310;CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: a ❑ 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 y ' the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If,"not determined," please explain. ❑ 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: El Observation of sewage backup or break out or high static water level in the distribution box tdue to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution,box. System will. pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced obstruction is removed Commonwealth of Massachusetts Title 5 ® coal Inspection Form, . ` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Deacons Court Property Address , Domenic Fazio ° Owner Owner's Name information is C required for Barnstable "MA 02630. M102/08 every page. !Town tY State " ; Zip Code =,Date of Inspection Ci , B. Certification et (cont.)-` , E) System Conditionally Passes(cont.): '❑ distribution b6x is leveled or:replaced ' ND Explain: . r r:- ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspectiohI(with approval of the Board of Health): ❑ broken pipe(s)are replaced,"' obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions;exist which require further evaluation by thefBoard'of Health in order.to determine if , the system is failing,to protect'public health, safety or the environment. 1. System will pass unless Board ofHealth determines in accordance with 310 CHAR " 15.303(1)(b)that the system is not functioning in a imannerwhich will protect public,health, safety and the environment: , El Cesspool or privy is within 50 feet of a surface water , , ❑ Cesspool or privy is,within.50,feet of a bordering vegetated a salt marsh` 2. System will fall unless the Bard 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: El The system has aseptic tank and soil absorption system (SAS)and the SAS is within . 100 feet of a,surface water supply or tributary to a surface water supply. ❑ •-,The system has a septic tank and SAS and the SAS is.within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. r r Commonwealth of Massachusetts Title 5 Official Inspection Form' .. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �Y 14 Deacons Court Property Address t , Domenic Fazio ' Owner Owner's Name information is Barnstable MA 02630 08/02/08 required for every page. Cityrrown State Zip Code Date of Inspection Be Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50.feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a-DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t Ae D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"t®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 g Discharge or ponding of effluent to the surface of the ground or surface waters ❑- ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑, ® Liquid depth in cesspool is less than 6 below invert or available volume is less than '/a day flow ❑ ® Required pumping more than 4 times in the last year Nordue 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. f Commonwealth of Massachusetts Title 5 Official Inspection Forte Subsurface Sewage Disposal System Form Not for Voluntary Assessments r 14 Deacons Court Property Address — Domenic Fazio Owner Owner's Name information is required for Barnstable MA 02630 08/02/08 _ every page. Citylrown State Zip Code Date of Inspection B. Certification (coat.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ Z Any portion of a cesspool or privy is within a Zone•1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform'bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be,attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one"or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000.gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section.D. Yes No TM ❑ ❑" the system is within 400 feet of a.surface drinking water supply ❑ E the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well ` If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered'a significant threat under Section-E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Officinal Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, 14 Deacons Court Property Address Domenic Fazio Owner Owner's Name information is required for Barnstable MA _ 02630 08/02/08 every page. Cityrrown State Zip Code Date of Inspection i C. Check list Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ -Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ® ❑ ty. 9 P 9 ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth:of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage.disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue ® ❑ approximation of distance is unacceptable)(310 CMR 15.302(5)] L_ CommonweaHfl of Massachtiosetis Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r r 14 Deacons Court Property Address Domenic Fazio Owner Owner's Name information is required for Barnstable ' MA 02630 08/02/08 , every page. tY Ci frown State Zip Code Date of Inspection � �" D. System Information Residential Flow Conditions: Number of bedrooms(design): =4 Number of bedrooms(actual). 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? a' ❑ Yes ❑ No Seasonal use? ❑ .Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump?. ❑ Yes ® No current Last date of occupancy: 't Date 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 Industrial waste holding tank present?i ❑ Yes ❑ No Non-sanitary waste discharged,to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ` Last date of occupancy/use: Date Other(describe): 4 Commonwealth of Massachusetts Title 5 Official Inspection Form'- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Deacons Court Property Address Domenic Fazio Owner Owner's Name information is required for Barnstable MA 02630 08/02/08 every page. Cityrrown State . Zip Code Date of Inspection D. System Information (coot.) General Information N Pumping Records: Source of information: Was system pumped as part of-the inspection? i •❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ,. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool F ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection record s, if any) Innovative/Alternative technology. Attach a copy of the current operation and ❑ maintenance contract(to be obtained,from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of-all components date installed (if known)and source,of informations 11/15/83 per BOH Were sewage odors detected when arriving at the site? 0 Yes No Commonwealth of Massachusetts Title 5 Official Inspection Forte Subsurface Sewage Disposal System Forms e Not for Voluntary Assessments 14 Deacons Court Property Address Domenic Fazio Owner Owner's Name information is required for Barnstable MA 02630 08/02/08 every page. Cityrrown State Zip Code Date of Inspection D. System !nf r 'y m ® i11BtlOf1'i (cost.) Building Sewer(locate on site plan): Depth below grade: 2.6 feet. Material of construction: a❑ cast iron ®40 PVC ❑ other(explain):' Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): i Septic Tank(locate on site plan): Depth below grade: 2.0 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ` ❑ Yes ❑ ' No ------------------------------------------------------------------------------------------------------------=------------- Dimensions: - - 1000 gallons Sludge depth: `5 .211 Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 7 14 Distance from bottom of scum to bottom of outlet tee or baffle - Flow were dimensions determined? measured " Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 94 Deacons Court e ' Property Address , Domenic Fazio Owner Owner's Name information is required for Barnstable MA 02630 08/02/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): .- Depth below grade: - feet Material of construction: , ❑ concrete ❑ metal ❑fiberglass` ❑ polyethylene El other(explain): Dimensions: w Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Deacons Court Property Address Domenic Fazio Owner Owner's Name information is required for Barnstable NIA 02630 08/02/08 every page. Citylrown State Zip Code, Date of Inspection D. System Information cont.) Tight or Holding Tank(cont.) Dimensions: — Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): , *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes No Distribution Sox(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. _ Pump Chamber(locate on site plan):' Yes ❑ NoPumps in working order. _ Alarms in working order: ❑ Yes [] No Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 14 Deacons Court Property Address Domenic Fazio Owner Owner's Name information is required for Barnstable MA 02630 08/02/08 every page. Cityfrown State . Zip Code Date of inspection D. System Information (cont.)' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number- 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - Comments(note condition of soil, signs of hydraulic failure, level of ponding,' damp soil, condition of vegetation, etc.): This system has a 6'x6'precast pit surrounded by two feet of stone. There was 30"of liquid in thepit L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forrn-Not for Voluntary Assessments 14 Deacons Court Property Address Domenic Fazio Owner Owner's Name information is Barnstable MA 02630 re 08/02/08 required for 4 — every page. City/Town State Zip CodeDate of Inspection D. System Information (cont.) 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 R 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.): Privy(locate on site plan); Materials of construction: Dimensions, - Depth of solids Comments(note condition of soil,'signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •y 14 Deacons Court Property Address Domenic Fazio Owner Owner's Name t information is required for Barnstable MA 02630 08/02/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage.Disposal System: Provide a sketch of the sewage disposal system including'ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Deacons Court = Property Address Domenic Fazio Owner Owner's Name information is Barnstable MA 02630 08/02/08 required for every page. �Y/Town p State Zip Code Date of Inspection C , D. System Information (cont ) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 7.8 Estimated depth to 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 describe how you established the high ground water elevation: augered to 11.0 feet and found no water. I adjusted to 7.8 feet. r Bottom of leaching is at 7.2 feet. Pe-.naF WL---ber: Dee= - -- cormvte.�_by: Lot Site c -8aan' - Owner: Adch-ess: 2ractoF: Address Notes: 40 it.0 to sie2rest VIG ft- ---------•-------. -------•--- - _ S i F-P 2 Us ngWater-Level Rt.-6 9-1 i i UAppropriate 3rdey Well _ . STEP ' S2ogo„':e5�.Sli�t_t.`a.3.'b•• 1 Ta .th?yam ! STFP i tD > :sear ; 3 for index tYe3€: (S- 2A ,. iv ,er f_ x.;nde wL�I S^34���3 ,, and ppr f zor*;STEP G8: _ � y ire i-.�4ee ..:....__P- zr-$eve'act;ts ent t, �;.em:tee mat . . *__stirnate depta`x<3 by Wbtradel'�g the fames � ^gh Yo tar :gye�et-te ---------------------- lam. ' PERMIT NO. ale DATE R OWNER �— ,�.� e F1q 'Z 0 s1 INSTALLER r� /� . M.��✓ f JOB LOCATION �i➢cr��✓ CWn� ��,�„rif�rfe��2 INSPECTION i ` —a DATE NEW CONSTRUCTION c 4� 1 � u1 \ C Y pov c� S r o o � 1 x � e - v e- . c v v. C+ C. Prudential (&,Yj Financial Henry P.M.Paap,CIMA Financial Advisor Prudential Securities Incorporated 60 Walnut Street Wellesley MA 02481-2153 Tel 781 239-8463 800 225-9184 Fax 781 235-8506 henry_paap@prusec.com t l 4. No................ G ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................_.............::....0 F...........................................---------......------------..........._........ • • AVVftra ion for Eliipniitt1 Works C omunr#inn Vamit .• Application is hereby made for. a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal . System at: i I. ... .c ...c:f".........��.v. � � -------------------- -•----•---•-------.........----...........---•---- -----.....------ Location-Address r t No. e..().................................. W tU /r Lei Owner � 1Addres CJ ��1�j�,s• ,.a ........................................................... ....... .......------......--•----- .... n...../� ..................................... Installer Address , �q 2 Q f+j UType of Building Size Lot........4.................Sq. feet .� Dwelling—No. of Bedrooms......................................Expansion Auk__(' Garbage Grier-(`) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a ...r. d Other res ._........-•-•.................................................------------•-•-------•-------------------- - ---•-••-•---...--------....---•---••-- W Design Flow gallons per person a dad. Total. �ilYo�' ��,-�-� ..--------- tons. WSeptic Tank—Liquid capacityl12,DV.gallons Length-__. -�p. Width..-t:: !... Diameter................ Depth. ........_:. x Disposal Trench—No...................:. Width.......I............ Total Length............ Total leaching area............ _.sq. ft. Seepage Pit No..._.__�...,_._.. . Diameter.._...._ .._.. Depth below inlet. ���f....... Total leaching area....-- sq. ft. z Other Distribution box Dosing tank ) ` ,p� Percolation Test Resul Performed by... ... ....,...G�._ ....' :.�:.9�. ,. Date....'...'..-t Test Pit No ..4:2_.minutes per inch Dep h of Test Pit.....:. . ... Depth to ground water...... r...' . fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a0 •--•--..I.......................................it ........................... ....L--................. .Description of Soil.....ja---.12......:LOA<�...�....12-....-....1z..---F-1.1.�F...-��Dt�S.�....I � � A���..�-may "�' �`� " :i:?..��_�f A, A�....c- AJ� i. ?4...... :..............................: U t!.,c.➢�,�►�1-----i.....0.��-�-'----".---O-�Q.`�.��-�-�1�3...a®�,sd_'--�---�-�--6�•'� ....��.r.et� 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 iITLij 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of ance has y the board of Health. . .................. r Date Application Approved' .� G ...... . Date Application Disapp oved for the following reasons:-----•---•-•--......----•--••---••----------------------•---•------------------...--•---•. -----------------------------------------•------------------...--•-------•---------•-•-•----...........--.•--•-•--.........-••-•••---•••------•------••••-••••-•-••-----•........-------•................ Date PermitNo......................................................... Issued......................................................... Date ' 1 No. Fm3 L�................ l THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF HEALTH �. ........... _...................OF..................................................-.......-----------...............----- ,XpV tratuan for 3liipna al Works Tomitrurtion rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System �. a.t..: .�SCd h ,�qr"b..� .... .... -- ---•---------------•••-----........----------•---•---........----...........................---••- Location-Address or t No ............................... L. .. g.f wt ��.... - ............... - .q. / � caner ' Addre Installer Address U Type of Building -� Size Lot.^ j0fc�'_._Sq. feet Dwelling—No. of Bedrooms....... ................................Expansion Attic- .� Garbage Grinder-t—� Other—Type of Building ________--_--.--•---_----- No. of persons............................ Showers ( ) — Cafeteria ( ) C I Other fixt res ---•-•......--•---......•..._-•--- •' W Design Flow.........J_ ..........................gallons per person �er d Total dail `f�ow-_----J V--0.......................gallons. f � WSeptic Tank—Liquid capacity_OMOgallons Length ..'.L.... Width+n......... Diameter................ Depth....}........ x Disposal Trench—No. .................... Width_.aj.---------_-. Total Length............... Total leaching area....................sq. ft. Seepage Pit No...._ ---------- Diameter...... '........ Depth below inlets ! _.-..... Total leaching afea.3.�d. ...sq. ft. Z Other Distribution box (A) Dosing tank( Percolation Test Results Performed by.................�._s, a�...._......_-�'� �r ............... Date..... .................. _I.._.._...... Test Pit No.&.5.7.-Az.minutes per inch Depth of Test Pit...!S........ Depth to ground waterl!!$71'.......__. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Y ..... O Description of Soil ih; -� kK: 1'H _ tr R Z�! ' ._l Q /...........Cej.--C C.Z. UNature of Repairs or Alt 1o,ns Answer when applicable.................................................. ............................................. -----------------------------••---...-----•-----...-•-----'-••----•-----•-------•---........-•--------------•-•-----------•----•---------------•----------------•---------------........................ E Agreement: /The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITLE 5 of the State Sanitary Code— The undersigned further agrees not to'-plfice the system in operation until a Certificate of Compliance has b s y the b rd of health. Si' d- ... ..................... •- Date Applica 'off A�Or�gd $ f Date...... . . ---- •. -- -- .. Appli 'tion Disapp ved for the following reasons:-• --•---•----•-•----•. -••-•-----•--•--•-•-••----••••.....-------•-----••-••..........--••-•---•••------ ..-••---.......•-•••-•.-•••---•-•------•-••-•--••--•-••-•••-•.....---•--•-•--•-••-•..............•---•--•._...........--•---••---•----'-••---•-----=-•-----•••--....---•--•-••--•----•---••--•--••------. Date PermitNo.......................................................... Issued........................................................ Date THE COMMONWEALTH .OF MASSACHUSETTS BOARD OF' HEALTH ..........................................OF...................................................................................... Tntif iratr of Toutplianrr THIS IS TO CERTIFY, That the Ir ividual Sewage Disposal System constructed (v<or Repaired ( ) by- ..... ............... .. y.... `---------------------------------------------------- •................................................. •••-.-.••••.-•-Installer at. - •-------------------------•--------------........._...•-- has been installed in acc dance with the provisions of TI F 5 f The State Sanitary o as ibed in the application for Dishos Works it, Permit No.... ............. dated_. tY. THE ISSU NCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE SYSTEM Vlll ���� CTION SATISFACTORY. DATE... ..1.£....l1 - Inspector_.... = .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH QOF.........:........................................................................... N� ... .......... � FEE........................ �t��r�a�tt nrk,� �nn�trttrtuan rrnttt Permissi?iseby granted ., ..,.� to Constr}G r Repair dividual Sevcg Disposal System at No. (--�- .7. -- Street as shown on the application for Disposal `'forks Construction Permit No.................... .....'��__.�.................. ...............................................��b/f /eailth� ........................................ ar DATE.......... ..................�• •-t�Z e,/ IT FORM 1255 A. M. SULKIN, INC., BOSTON _ PERMIT NO. DATE OWNER ,,, c f i4a, Z� A D D R E �ef�qso� �dd� f" �iv•..�s�� -c AV �s s INSTALLER .SA�ej �.4"/ JOB LOCATION e�co�✓ �y�n� (�i9.,.ys 4ve INSPECTION lfj/y 1A DATE ` NEW CONSTRUCTION Ad Oaf } _ w 0 y 3(-.2.4 \jj yam, & I �-,, , C. 1�, 37 t!f C R1 d i`,Ao pa i f?X[{.4 t is t_-t � 4�.q`9�F+.?- ?•► "4;;' /i /'f �, r YC.: - , . �i EL 1fl ' 73 a w7� ' 34 0. IV 00 I r-T pf N 447rS0 - pq a.. 3 ..3 r.4aF� ` tSN pRep ` t rq ZY /04 -- _ i 6L EVAT!0,0'S 3Q E ; LtT � . M Nf Um l+ ..pi)4a SG .. �.lz 0A t�1.19N vE. Jam. 'y I thl ' ;F 'f- pdF .:��►118H :QRAt71S _ ClYEst. .#� • ,N , �� i�at • E�f�N''�' fir ::. o �4,40 M � WOW mil. ;+ o" �`[�iV� ►�' � ,ice} ^`"y t t ►1. � �. N .� vJA boa s0 Mr: _. .Z::QD ► H tom© .� � 4.Q:7S' a 3 l► G�"�, GALL.Om 41mlrt I A�� 41..00 8MI G YAWl4 F'tt'g. 3�t34 , •Q o4 o- • ,a 5E�1 C sysMAVIAQ AA CON sTa Uc•-tON r 5 ALL CONFORM 10 'THE MAS6. 91 ,/1 R oNM EN TA 1. CODE TITLE� R v Isev 7- 1-17 Z4 I-HF- 9't7v1f/4 j, i=1 Dt✓°ol�+� . .ov� R:t7 Or N ►>�'T�-t t, t t au ,p►'1�0r4� 1 `r` f, Oaf SEPTtG'tAN1C 01STRi a fYoN t�� Atv nAb t'NEa �- ro 13� Ole LeACk RAM � � C,A� At Gi'i'�`� H to LOAo1 r4cq ®�Lh�E ►� r4or -r® L;F d� � 1G'SI CAN LOAPI C:r U9-560 CRAiG RAYMQW �. LCXA" IMJ, %j MA /'� TQ O /`+T 1►G t°iT 4' rio. ?718� ..r y 3y�rgAA Tb P>S 09 F1� S �''OFF . Rr. OFE[95 'f��°5 a �� 1� � P�>r-C�►�►`T `--'`'- ✓ �. ,t , � .�; _,.,, �1. _1-:�� .._ �I ® UC�IC.aNI�v 13U11LDIN'I { I !, ALTO-i Cad p►PPC�G �EN�JIS MASS � � � 385 -- 2831 . ,