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HomeMy WebLinkAbout0075 DEACON COURT - Health 7 5 Deacon Court Barnstable A= 300 -058. I TOWN OF BARNSTABLE P LOCATION [ 4 e4,AJ (f6 U4 4 SEWAGE#;!b J J� U VILLAGE gjk aO,)3 ASSESSOR'S MAP&PARCEL 3bQ, INSTALLER'S NAME&PHONE N043 c >�4i• < eG/zo— > SEPTIC TANK CAPACITY /4130 :2-01elef LEACHING FACILITY: (typ� fee. 6410AX S(size) �x j NO OAF BEDROOMS OWNER PERMIT DATE: J COMPLIANCE DATE: �- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY r . i� ,�.i �� �� ��. � �� � I i�6 �1i ' ;,® NO -/� THE COMMONWEALTH OF MASSACHUSETTS FEE ® v O� �a, BOARD OF HEALTH I0*1V OF APPLICATION FOR DISPOS SYSTEM CONSTRUCTIO PERMIT Application for a Permit to Construct (�^) Repair ( Upgrade ( ) Abandon El❑Complete System ndivi�duallCCo�m�ponents 7C�ca' n Owner's Name /Parcel# Address CLot# T e hose# �J 1 nstaller's N�m Designer's Name ddress � ress �7elephone#F a Tele ,hhone# Type of Building: e Lot Size y A<1, Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. q red gpd Calculated design flowl�gpd Design flow provide J gpd Plan: Date 1 Z' Number of sheets I W ev' ' ate Title Description of Soil(s) - Soil Evaluator Form No. 55aj��Name of Soil Evaluator Date of Evaluation DESCR TION OF RIEPAIRS O ALTERATIONS The undersig a ee to install he above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu ag s of to plat the system in operation until a Certificate of Compliance has been issued by a Board of Health. 6 Signed Date ZJ Inspections FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 Town of Barnstable Regulatory Services ' Richard V. Scali Interim Director rri BMWftABLM MASS. Public Health Division . Thomas McKean,Directory 200 Main Street,Hyannis,MA 62601 Office: 508-862-4644 Fax: 508-790 63_04 Installer&Designer Certification FormIL ' Date: �7i Z► Sewage Permit# Assessor's Map\Parcel Designer: )1� Installer.. - Address: 6A4jT �?AAO Qb4 Address: On � �� � was issued a permit to install a (date) costaller). septic system at 75 VOL - U used on a design drawn by (a``ddress) - � tl dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank.` Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations..' Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. - I certify that the system referenced above was construc_;�_ : *,fiance with the terms of e IAA approval letters (if applicable) �t�OFAtgs� ti DMID NIASON m _ sta l s Signature) o p No.1066 �cIS iE�� (Design s Signature (Affix Designers Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION.~ CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Sepric\Designer Certification Form Rev 8-14-13.doc F THE COMMONWEALTH OF MASSACHUSETTS FEE ST BOAR�jD, OF H EALTH r 1(�W _O FIF APPLICATION FOR DISPOS TEM CONSTRUCT7ndiidual PERMIT Application for a Permit to`Construct ( ) Repair ( garde ( ! ) Abandon ( ) - ❑Complete System Components i( T�t,"1 Gov Loca' Owner's Name NAP/Parcel# Address "V�Lot# �•jV��`�%�'�i/�1 1 "� �� hone#1 � j t�,. t nstaller's N m Designer's Name 7Telephone#1 Telepho ne# Type of Building: / '�-C� �rl Lot Size l.ZZ AVTj -Sq.feet Dwelling—No.of Bedrooms ! Garbage Grinder ( ) ' Other—Type of Building AbolfoPusotisc-1 Showers ( ), Cafeteria ( ) Other fixtures 1 Design Flow(min. r d� gpd Calculated design flow"�gpd Design flow provide gpd ' ' Plan: Date I � Number o sheets ev: to . Title \ 0 L ) W` Description of Soil(s) Soil°E,valtiator`Form No. Name of Soil Evaluator I Date of Evaluation DESCR PTION OF RjEPAIRS OR ALTERATIONS ~]� 1 I The'under%aee/tonstall he above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fuplat the system in operation until a Certificate of Compliance has been issued by a Board of Health. -- Signed Date ( Z J i Inspections r FORM 1 APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. /G p E COMMONWEALTH OF MASSACHUSETTS t FEE `� 'jU� 1\ BOARD OF HEALTH C Rf FICATE OF COMPLt NCE Description of Work: Individual Component(s) Com ete • stem❑ ,et y The undersigned hereby certify that the Sewage Disposal System;Constructe ( ),Repaired�aded( ),Abandoned( ) by: CWMM/t at 71 5A49�si G has been installed in accordance with the provisions of 310 CM , 15.00 (Title 5) and the approved designplans/as-built plans relating to application N 17-%& dated I y C Approved Design Flow _(gpd) Installer l► DT- t Designer: Inspector Yt Date 1 1 The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE. bEP APPROVED FORM 5/96 4 No.C�DI� �" / THE COMMONWEALTk,,�OF MASSACHUSETTS FEE JOG e, BOARD OF HEALTH - DISPOSAL-SYSTEM CONST UCTION PERMIT Permission is hereby gran ed to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at 10— 1 as described in the application for Disposal System Construction Permit No. ,.dated- Provided: Construct on sh 11 be completed within three years of the date of this permit. to al cony tions must be met. 7) Board of Health Date a FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON _ Town of Barnstable .P it • dPTMe Department of Regulatory Services, Public Health Division Date NAML s ��P '200 Main Street,Hyannis MA 02601 k. Date Scheduled ~:Zo Time Fee�Pd. �� Soil Suitability'As essment for Sewage Disposal. . Performed B Y 1 �'"'r•1" �f r y'�- �!'j "t� �d Witnessed By:�i _LOCATION & GENERAL INFORMATION Location Address 75-P�,.�, i f � Owner's Name" l lJvy (>lJV Address Assessor's Map/Parcel: t�' - Engineer's Name P1>+ NEW CONSTRUCTION REPAIR Telephone# 5761161 Land Use Slopes(%) l "Surface Stones Distances from: Open Water Body ft' Possible Wet Area -ft Drinking Water Well ft Drainage Way ft Property Line' ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes), Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole:' Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: - Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level _ PERCOLATION TEST Date Time Observation Hole# 2 Time at 9" Depth of Perc Time at 6" ' .e , Start Pre-soak Time @ Time(9"-6") • f t r End Pre-soak. s Rate Min./Inch 5 Ail41 :�� T - Site Suitability Assessment:,Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division -Observation Hole Data To Be Completed on Back----------- ***If percolation test is to he conducted within.1001 of wetland,you,must first notify the Barnstable Conservation Division at least one(1)week nrior to heuinninu. 4 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon. Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel -� r i `. dLo s DEEP OBSERVATION HOLE LOG _Hole# Depth from' jSoil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. I Consistency.%Graven } DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) , (USDA) (Munsell) Mottling (Structure,Stones,Boulders. j+ # Consistency,%Gravel) � I i. i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate Mau: Above 500 year flood boundary No Yes '► Within 500 year boundary No_ Yes Within 100 year flood boundary No— Yes { r _ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio in erial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of aturally occurring pe 'ous material? Certification I certify that on 10 41 (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was performed by me consistent with the required train�expertis�da Senie ce escribed in 310 CMR 15.017. Signature Date " 17 r Town of Barnstable Barnstable Regulatory Services Department AlAmedcaCity HARNSrABM y , 6 9. Public Health Division I m `V 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 5336 October 31, 2017 THOMAS, DAVID C & DEBORAH K 75 DEACON CT BARNSTABLE, MA 02630 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 75 Deacon Court Barnstable was inspected on 10/23/2017 by Brett Hickey, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines. of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the_ invert pipe (per Town Code 360-20 h). You are ordered to repair or replace.the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action, PER ORDER OF THE B - RD OF HEALTH 6 Thom r ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\75 Deacon Court Bamstable.doc Town of Barnstable Regulatory Services Department BEd MJd Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-862-4644 Richard Scab,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLI1,vES TO'REPAIR FAILED.SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An`k"marked in the ❑ is the failure criteria and associated repair deadline 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 or obstructed pipe ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy.below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 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). . TWO 2 YEAR DEADLINE CRITERIA , ❑Any"conditionally passed systems (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level,<12"below inlet (per Town Code §360-9.1) Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: a\SEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w� •r� 75 Deacon Ct. Property Address he�d David & Deborah Thomas Owner Owner's Name information is Barnstable �/ Ma 02630 10-23-17 C required for every - �a page. City/Town State ' Zip Code Date of Inspection Co Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation rab Company Name - 374 Route 130 . Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-23-17 Inspector's Signature Date The system inspector shall'submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Ilk bus Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17, page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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: r 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 FIND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ ° 75 Deacon Ct. M Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken; settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ` ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. .1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. City/Town 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 ® ElBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Deacon Ct. Property Address David & Deborah Thomas - Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public.well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails.-1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E) Large Systems: To be considered a large system the system must serve a facility,with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section'D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone IL 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 .3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 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.s stem recent) or as art of ❑ ® Y Y P this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) �I ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of breakout? ® ❑ 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/GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: .3 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage, See below 9 ( Y (gPd))� Detail: 2015-40,000gallons 2016-40,000gallons Sump pump? - ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 75 Deacon Ct. Property Address - David & Deborah Thomas Owner Owner's Name . information is required for every Barnstable Ma 02630 10-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Date of last pump is unknown Was system pumped as part of the inspection? - ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ 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 x Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1978 per COC Were sewage odors detected when arriving at the site? Yes No Building Sewer(locate on site plan):. Depth below grade: 3'6" feet Material of construction: ® cast iron ® 40 PVC. ❑ other(explain):_ Distance from private water supply well or suction line: Town feet Comments(on condition of joints; venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2'6 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, Iist age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gallons Sludge depth: 9 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " ,M 75 Deacon Ct. Property Address , David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27' Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 t5ins•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 M 75 Deacon Ct. Property Address David & Deborah Thomas - Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal - ❑ fiberglass ❑ polyethylene ❑ other(explain): 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1M 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" , Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was in poor condition when viewed. 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.)-. NA * 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. City/Town State Zip Code -Date of Inspection D. System Information (cont.) Type: ®, leaching pits number: ' � I ❑ leaching chambers number: ` ❑ leaching galleries number: ❑ leaching trenches number, length.- El 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.): Leaching was in hydraulic failure. Liquid level was over inlet invert and backed up into the riser at time of inspection. Cesspools (cesspool must be pumped,as part of inspection) (locate on site plan):. Number and configuration NA 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 F Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 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.): Privy (locate on site plan): Materials of construction: NA 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form * ; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments', 75 Deacon Ct. H SV ye Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 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 A . t eletric meter B 31 1 2 d-box. 61-19`A 54` 1500 gallon tank 2. B2-30' A3-73' B3-46' Vx6'pit l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1M 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) r - Site Exam: z ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >.13' feet Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record 5-8-78 If checked, date of design plan reviewed' Date 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: Plan on file with BOH. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,^M 75 Deacon Ct. Property Address David & Deborah Thomas Owner Owner's Name information is required for every Barnstable Ma 02630 10-23-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE SEWAGE # iLLAGE ASSESSOR'S MAP & LOT�v NAME&PHONE N ;�;2�— J SEPTIC TANKJV LEACHING FACILITY: (type) NJ (size) �D"k 6a r NO. OF BEDROOMS BUILDER OR OWNER Cev PERMITDATE: Cl- 7 COMPLIANCE DATE:1�)'JL>7k' Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by-- e} Dqy • L0 C A T 10 \V jn SEWAGE PERMIT NO. ��COVI VILLA E Vv�+ 3 oac ` INSTALLER'S NAME i ADDRESS l B U I'L D E R OR OWN ER J DATE PERMIT ISSUED �-_ cl DAT E COMPLIANCE ISSUED �� � JC9 7i ' P f � a V+ �G MSESSG-RS MP N0: 2M_c 7 PARCEL NO: No • THE COMMONWEALr'H O1F'_d9ASSACHUSETTS BOARD OF kEALTH 3 —f ..__�.�?.W.1V...................OF......��i../�./SST./.Q/�-G.�........................................ Appliration for Mir wi al Mork Tomitrur#inn Prrmit Permit Construct r Repair an Individual Sewage A llcatton ;<s hereby made for a Per t to Co st ct ( ) o p ( ) S ge Disposal Syst at: A? W °? .6............---------------------------------------------- L_ Locatio -Addres .................................Lot.No. --�=_---�'- - .��--Vie.-----•---------------------- ------------ ............................................... Own Address w ....................... ------------------------------------------- ........................................... Install Address Type of Building Size Lot_.,5.3..00.0__`_Sq. feet aDwelling—No. of Bedrooms___.____._.___ __________________•___Expansion Attic (jjp) Garbage Grinder �� p, Other—Type of Building ...NIA............. No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures __________________________________ ---------------------------------------------------------------------------------------------- d W Design Flow...........//0.......................gallons per per day. Total daily flow---------33.0.....................gallons. 1:4W Septic Tank—Liquid capacity./5 gallons Length/O.`A6�... Width.�`R-_'�- Diameter................ Depth. `..'s x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._._-/............. Diameter...f0-.._-...... Depth below inlet..... ....... Total leaching area..a.6.7..sq. ft. Z Other Distribution box (I/f Dosing tank ( ) a Percolation Test Results Performed by.7?0A)A_4b....14__...C`t.1 _4.•.._ _... Date_AR.Ri.c...•J. ��-/��� Test Pit No. l L,.w2._..minutes per inch Depth of Test Pit../I-N_...... Depth to ground water........................ Test Pit No. 2__4.9_....minutes pep inch Depth of Test Pit./ _.......... Depth to ground water........................ Descri tion of Soil...it •-----•-O...:n-3.1--44A.M... ...S49!U�c -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.____._......................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signeo...• h••-•-••••-•----•-----------------------•-......_----•---------- ............Da-•-..._........ // Date Application Approved By--•---• - •••-- ........._ l t�L� ---•--------- ...� -Q" 7-r..A....... - ---•-Date Application Disapproved for the following reasons:--_----•-----------------•-•.--•----•-------------------------.--_-------------•.-__-- ----•--- __--- ....................•------•-----•------.....------------.•...---•-----.......-----------...---.:....-•-------------------------••--------------------------------------............................... Date PermitNo......................................................... Issued_...................................... Date No. -- ... - F�s...'�....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Applir�ation for Di,spsFal larks Tonstra.rtinn permit Application is hereby made for a Permit*to Construct ('!' ) or Repair ( ) an Individual Sewage Disposal System at .. ' 8+ . 2" ' --- .......... ......S -......................................................... Lo.a o 'Add res ; or Lot No. Owner Address W Installer Address Type of Building Size Lot_ , ......Sq. feet Dwelling—No. of Bedrooms._-___ __ _______________________Expansion Attic (k0) Garbage Grinder pa, Other—Type of Building •"-/ - _;______ __ No. of persons._,.......................... Showers ( ) — Cafeteria ( ) a' Other fixtures �W Design Flow........... '8( - ... gallons per per dray. Total daily flow--------��0.....................gallons WSeptic Tank—Liquid capacity/5a00_galloas Length/a�_i_ _ __ Width � . Diameter.__--.___--_--_ Depth_V ._.. x Disposal`Trench—No_ ____________________ Width.................... Total Length......... _.____.__ Total leaching area__._.___..__._______sq. ft. # Seepage Pit No----/_.....__.... Diameter---14-_--___-__ Depth below inlet.__._ . Total leaching area_. _t�i_ ----sq. ft. Z Other Distribution.box (44 Dosing tank ( ) Percolation Test Results Performed by.7*eb V C�!___.I r___: E / Plt _ •fix.___ Date_ Rtf s 1 a 10 Test Pit No. 1 __`6..`._minutes per inch Depth of Test Pit_,✓3.A....... Depth to ground water_ ____________________ f=, Test Pit No. 2_4A .minutes per inch Depth of Test Pit,/V a Depth to ground water . O Description of Soil � `��-r-•---O r ...__ZO�It( IU40 t 1 ' * a. ' C78/�1f 0 �3L+ (xj __p'��4__r.rI!?, +�7'E$/ .t --• + t s'�' a��''�t - ! �! ?G�"' 4i�.t -------------- W -------------------------------------------------------------------------------- ;----..---------------•----------------------------------------------------•-------•----••••-•--••-----------••--•••-- UNature of Repairs or Alterations—Answer when applicable............................................................................................... } Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe - -----------------------•---•-•---•--••--------•-..-•----------•--•--_-••-• ................................ Date Application A roved B .......... __ . Date Application Disapproved for the following reasons------------------•-----------------•--------------------------•-----------•---•---------------------------_---•- ................•----••-•-••----•----••...•--•-••--•-••-•----....._..._..-•••-•--------••••••••-••-•----•--•••---••--••....•-----•••-----••-----•••-•------------...................................... Date PermitNo...................................:..................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF :HEALT ....... k .... ..OF...... ...... ... f9rdifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (' or Repaired ( ) by - •---- ....•--•- ............................. Inst at..r.�.�. ._.I .f.: _ . c. •--- ' d ----& k z -r Vic.i has been installed in accordance with the provisions of T >a f The State Sanitary Code as described in the application for Disposal Works Construction Permit No. ._ ' !k y ___-__.___. da.ted...... ......` _.'__ _ _________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI, ACTORY. /,^ --at 40 DATE. ---•........................•-- • ......................... Inspector------- ---• ------------- ->----••--•.........---------••••y•-••-••-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �. No ...... �./:... .......O F.......... . �l-............................................. ;FEE.. .. `... : f Disjuasal Works. Tnnstrnrtion rrmit Permission is ereby granted....... _______ ,E sl _____� 1 ____._._.___. to Construct ( r Repair ( ,) an Individual ewage Disposal System at No..... _,�. !Z^ 6.......•DAL.. _C��?.!s!_._ r.,G.Z4.7- ----------------- ,�-',?��W�_?'.�.C.��1+��� .------------...._........... Street as shown on the applicationfor Disposal Works Construction Peprq No_____ ___ ______•�_ Dated____ "__�'��.............. f� -_____----•--•- ' ''-j ,� B €oar DATE.......... -=` �=-�- •�•--f.-----------------••--- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS � Pas -\ COMMONWEALTH OF 1VIASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ~� DEPARTMENT OF ENVIRONMENTAL PROTECTION . _. a 1 tg- TITLE 5 OFFICIAL INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS SUBSURF:kCE SEWAGE DISPOSAL SYSTEM FORM , PART A ERTIFICATION Property Address:r/ rA Alp "A Owner's Name 31 off. Owner's Address:' Date of Inspection: Name of Inspect (please print) Company Name. P1Z .�i /' v 'dui 010rd, ��/7j' ' Mailing Address: POZ& '72V `l Telephone Number:, Qt,-2 7/ rr rt CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as,of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ..Inspector's Signature: Date: _ �VG0 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 thisrinspection. If the system is a shared system or has a design flow of 10;000 gpd or greater,the inspector and the sys,-em owner shall submit the repor`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. :. Notes"and Comments..... - e ., «.,.•�..�. ..{.,� .err.". .si.+a._ r« ..a � �,r`V 4 � �nw�ASS.`.::._., - ._ ._ .._.�,« ...._ ... ,. _ ,. ., . .� ...r'y +•� ° .F.� . ��. . i ****This report only describes,conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM---NOT FOR VO-L,*UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: A 1-44 Owner: Date of I spection: JpU Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any informatior which indicates that any of the failure criteria described in 310 CMR 15.303 or m ^�10 CMR 15.304 exist. xtst.Anv failure criteria. _ ia.not evaluated are indicated below. Comments: ! * y B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair-as approved by the Board of Health. Will pass: Answer yes,no or not determined(Y,N.ND) in the for the following"statements. If"not determined'.'please explain. sr. 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 ir,�iminent.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 inspectio;_if it is structurally sound,not leaking and if a Certificate of Compliance indicatin g that the tank is less than 20 years old is available. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: The system,required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Roard of Health); broken pipe(s)are replaced obstruction is.removed ND explain: Page 3 of 11 a OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM 4NSPECTION FORM PART A CERTIFICATION (continued) Property Address Owner . Date of Inspection: C. Further Evalua ion is Required by the Board.of Health: e Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failinc to protect public health, safety or the environment. r 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment. Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh- 2. System will fail unless the Board of 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 mnk 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 tatik and SAS and the SAS is within a Zone l of a public water supply.. The system has a septic 61hk 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".jMethod used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: 4. i Page 4 of 1] . . t OFFICIAL:INSPECTION FORM-NOT FOR VO' UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Q Owner: Date of I spection: r D. System Failure riteria applicabie to ail systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N 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 J clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT di o to clogged_or obstructed pipe(s).Number / of times pumped Y Any portion,of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy.is within 100 feet of a surface water supply or tributary to a surface Water supply. . Any portion of a cesspool or privy is within a Zone 1 of a puE>lic well. Any portion of a cesspool or privy is within 50 feet of a.privat water supply well. Any portion of a cesspool or privy is-less than 100 feet but grater than 5.0.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 colifornr bacteria and volatile organic compounds. indicates that the well is free from pollution from that facility and the presence._of ammonia nitrogen and nitrate nitrogen is equal to orless than 5 ppm; provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I h.a-ve.determined that one or more of the above failure criteria.exist as described in 310 CMR 15.303,therefore the system fails. Thesystem owner should contact the Board of Health to determine what w_ll 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• You must indicate either"yes"or."no"to each of the following: (The following criteria apply to large systems in addition to the criteria'ab'ove) yes . no — _ the system is.within 400 feet of a.surface drinking water supply, the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellh .ad Protection Area—I WPA)or a mapped Zone II of a public water supply Y 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 15.3 04.The system owner should contact the appropriate regional office c.:the Department. Paoe 5 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:. Owner. Date of I pection: Check if the following have been done'.You must indicate"yes"or"no".as to each of the following: ai Yes No Pumping,information was trovided b the owner,occu ant, o-Board of Health - F Y P ' 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? LI _ 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 bark tip ? ' — Was the site inspected for signs of breakout ? — 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)cn the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. fi Determined in the field(tf4ny of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)j'fb)] 14 IA .r 5 Page 6 of I 1 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE) 'AGE DISPOSAL SYSTENI INSPECTION FORM PART C. SYSTEM:INFORMATIQN Property Addres : / Q r r t. Owner: ��,d .Date of I spectio,i'k `%d4— o FLOW CONDITIONS RESIDENTIAL Number of bedrooms(:design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder ayes or no): Is laundryon a separate sewage system ( s or no [ if es separate inspection required] d ] Laundry system inspected(ye,.or no) Seasonal use: (yes or no):_`U Water meter readings, if av (5 Z '" P ilable(last 2 years usage g d :03 400i�� 0OTAw )) Sump pump(yes or no)A, Last date of occupancy: COMMERCIAL/INDUSTRIAL N 0 Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):._ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER.(describe): ' GENERAL INFORMATION Pumping Records r Source of information: / Was system pumped as part of the i spection yes or no)� t :k , If yes, volume pumped: gall6ns - How was quantity pumped determined? Reason for pumping: TYP 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) _Tight tank —Attach a copy of the DEP approval ;. Other(describe): proximate age of all compone ts,date 'nstalled. if own) and source of information.- Were sewage,odors detected when arriving at the site(yes or no): Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G .. SYSTEM INFORMATION(continued) , Property Addres : 0 Owner:', Z Date of I spection: V x�za� ;. BUILDING SEWER(locate on site plan Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well.or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade Material of construction: . C ncrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions* '1C�' .,�!"�� SCj Sludge depv; Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: _, !/ Distance from top of scum to top of outlet tee or baffle: Z �/ Distance from bottom of scum to bottor f outlet tee or baffle: How were dimensions determined: Comments(on pumping recommefidaticns, inlet and outlet tee or baffle condition,structural integrity, liquid levels as lated to outlet invert, e i ence of leakage,Al GREASE TRAP.,&locate on site pltin)-U-/-k.J ZzTdo/vu�I PGk Depth below grade:— Material of construction:_concrete_metal_fiberglass polyetlylene_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: Comments(on pumping recommendations;,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR YOtUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,. SYSTEM INFORMATION(continued) Property Address: UdCQvU Owner: Date of I spection: _� FCC "' TIGHT or HOLDING TANK:(tank must be pumped at time of inspection)(locat.e on-site plan) Depth below grade: Material of construction: concrete metal fiberglass_pc,Iyethylene other(explain):. Dimensions:' Capacity: gallor_s Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): •: r:r. DISTRIBUTION BOX: if present must be opened)(locate on sit�plan) sR Depth of liquid level above outlet invert: Comments(note'if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of ja g e into or out of bo�e ) PUMP CHAMBER:(locate on site plan). Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition.of pump chamber,condition of pumps and appurtenances,etc.): h 'A . R Page-9 of 11 OFFICIAL INS PECTI07N FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: AkA Owner: s Date of In pection( 11-A-9 !Xanas SOIL ABSORPTION SYSTEM (SAS):zoocate on site plan,excavation not required) If SAS not located explain why: s -- Type leaching pits,number: . leaching chambers,number: leaching galleries,number: leaching trenches,number, length:, leaching fields,number, dimensio'hs: , overflow,cesspool,number: _ innovative/alternative system TVpe/name of technology: Comments.(note condition of soil,sign. of hydraulic failure,level of ponding, damp soil, condition of vegetation, et CESSPOOLS:%' (cesspool must b,;pumped as part of inspect ion)(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 orno): Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.): PRIVY:/ ib (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.): y t ;1 py 9 ,1 Paoe 10 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYST:.+,' INSPECTION FORM PART C SYSTEM INFORMATION°(continued) e Property Addres A Owner: _ Date of I spection. `S SKETCH OF SEWAGE DISPOSAL SYSTE M 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. V i SV �. � A Page 1 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART C SYSTEM INFORMATION(continued) Property Address: "A . Owner: Date of In4pection: � SITE EXAM Slope A Surface water Check cellar —Shallow-wells • . �f £' Estimated depth to ground water Z f+; feet Please indicate(check)all methods used to determine the hieh ground water elevation: Obtained from system design plal!is on record-If checked,date of design plan reviewed: 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 elevatioau n: q s riot �, it ,i 11 il ,i3 • Perrnit Number: Date: V Completed by: / HIGH AROUND-WATER LEVEL COMPUTATION Site Location: Lot No. Owner: Address: y— Contractor:_ ,�/�l �G7 ' '! U��yJ� Address: !�,6— Notes: -'�f�v�ST �S�•'�'fl STEP Measure I asure depth to water tableto nearest 1/10 Tt. ..-_. .........-:............................................ .Date` l month/day/year - - STEP 2 Using Water Level Range Zone and Index Well Map IDcaie = = =- site and determine: ; OAppropriate index well _:_.._:.. Z_ O Water'-level range -_�ne ................ ..................................... STEP 3 Using monthly report`'Cutrent - Water Resources,Cond=iAs' : - determine curren lt.depth •'' `-�.� _ water level for index month/Year = t . STEP 4 Using Table of Water- erel'',;adjustments for index well (STEP 2,6, 'durrent depth w: to water level for inde% well (STEP 3), i and.water-level zone (},EP 2B) determine water-level az-justment .................... STEP 5 Estimate depth to high water by subtracting r o ciin the . a - � rer- level adjustment (STEP 4 from measured depth to vrater level at site (STEP S T ) 1 ( -- ....:............................................. - -= ilai -"tom . •.� - 'sue, __ - Ficui8 --Reproducible 's•'_ - 13. Re roducibl - --- -_�. p .,con; utaiion i di ,`}' ' r �� , ''_yam?• SS 3 I i:. ..:lob _ .......... .......... . _._...__...._................- t i _ f a I. ! f Lw �+�ryr.�y 1.�`` i ! r0 x� Y7 :;:r7;`V ) .t (.• t. - _ ; ..R L :7 '`L�ti A l7 F - It n 4 7 45 LA WST SEPtiC 1-5 a MINIfft / .7ES ' f ti� . 1 fi ON T 3O t ZA v Pxm f.zv 30 f: _�; P2 o p0 5ED SE D T/G 5 y5 TEn4' COn45.-re UC T/ON SHA L Z., Con/F OJzn�t To .�9a sS.: l7�5/G n/`. FL<O lit/ l GAL17A Y EN vrt e OAJ^4 V 7A— CoD� Ti,Tt REIf/SE :7�-I 7•'/ . _ A ' I TAif� TE` M/ .j//t/GN' ,� P2oPa5�A /70P OFE L7-Al C,UG..t 7'T 0NS' /�GC� FO.�yt�/D.AT/D�d w- P2ox 1o5 E b .L EAi;- MAnY G o✓ ki TO x TEnID TO P/ //5,gE-D 3,43 lO - F20r+-! /NF/L_T2AT/it/F� Co VAZ 2%G24vE Q' Bo Z/"/pa Ol/E,e CAST/i20,�J — '� —— — 3"MrN I P77T D/ Ar /TC�/ FtOw LiA/EAvl _�. IO"MInV �4'�FOOT /¢ 4 �FooT 2 Mrni �i rs fi Y i D/A. " /�.=f. .2 _Y_ �*� AliN ✓�"/cool_ " � c WAS HEO ST0A./E GA'L_L 0N/ /NVE,2T ALL //V T CA PAC/°Ty A20un/O SE'/OT/C TA A./.-- / Ea-FL V. e / e' $CdTQitd• Of- ra: (WA�G IZ T/G h�T� l N VE2.T /NVE�T L( �D _ GA,2E3A6E,-��NDE�.. C`Y E Si) . , �---�l is.0 ��1�.`, 20 6.. >c 2, ^ NOTE R-f; S IL. A,�tA GLAi i0 RR.011N1� PITS €PCs` . 'i'l%E '$ RIS 2, /7 LOG,4 T/D/V ►f?1�! S ,� AND. RE Pt.9c f. V_) .�-W7ct 6AN M�',�l r'�4'. r �2 EFL 2 Enfc E L �t _sAN6 0 t�+�'510 4�' Z' 557TOA/e ° t"? E l ,- K �, . 0 �� SEPT/G TANKS 1�/5Tf2iE3UTiON 80�' - $ UTLETS� A/,/D L.E<lC ol-I/Aa/0. �/T -RIONA3� BE.- O. )2�iA/F0A- --Z7 GO.vC.2E7'E° ,. JART1�l1+f ; �, _ }} s � NG'i2ETE ST.eEAA57;;/ 3000 �`/ .. L i 1 SER t'1 1aa. #x3 5± EEL 20000 f1— /O LOAD/tiG 69 W/4 4.0�' '��" a: �/vE way NoT ro ems. LoC.aTEa ` OVEN 5YSTEM UN[LE_S5 h!- 20 Al,,,- -Sl&AJ LO-4L�/NG /S USED. =I CERTIFY THE. bUUUILDI GI i�SIVOW'' O'N T�;i/ j r f 15 PRO -SED ON -FnC. G'RC7t✓N AS ? ' 160W�: ,/4'FYd IT D0 CG3t� t=O€2J"t' 1A11 N ' w. Al SE J(.�r?C f� - R�•Q���#•.��t�"1�C�#'�,a � "�"1!�' ?C7fu'1V"^ � �G/�T OF QAi?f+ISTASL Z>A.TE y .4LTt-/ AC-51_ /7— , - . - e •h. ASSESSORS MAP: -,k'fj00 �J PARCEL: � �� - - TEST HOLE : LOGS ,�` 1 The installation shall corn , Mth Title V and Town o oard of SOIL EVALUATOR: I ► 1 �A Gyl'J ) t FLOOD ZONE: I�-�� IC�V����, T I lealth Regulations. i WITNESS: p 2) The installer shall verify the location of utilities, sewer inverts and septic REFERENCE: e - DATES r: components prior to installation and setting base elevations. } PERCOLATION RAT : 3 All gravity septic piping to be 4 inch Sell 40 PVC at 1/8" per foot. The first two feet out of the d-box to the leaching shall be level. TH-2 4) This plan is not to be utilized for property line determination nor any other h purpose other than the proposed system installation. �, _� 5) All septic components must meet Title V specifications. Wy kk 6) Parking shall not be constructed over H10 septic components. 8) The property is bounded by property corners and property lines. t b (o �� t �� ) he property owner shall review design considerations to approve of total , LOCATION MAP (Oti� � � �2 . � design flow and number of bedrooms to be considered For design. Receipt of payment for the plan and installation based on the plan shall be deemed 2 approval of the design flow by the owner. U 9 The existing leaching or cesspools shall be pumped and filled with material � ) g g P P P I per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per �� - U � 9?�� �DQ (r , �� Title V specs. x+ . �, 10)System components to be 10 feet from water line. Sewer !fines crossing the i 1 "1 \ water line shall be sleeved with 4 inch SCII 40 PVC with ends grouted if I ` applicable. The proposed SAS is being installed below the water service " line. The line is to be sleeved as aforementioned and maintained in place. �. S E P T I C. SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the s owner to ensure such. FLOW ESTIMATE ! 12)The installer is to take caution in excavation around the as line if such g �\ 1- exists. BEDROOMS AT � GAL/DAY/BEDROOM - �GAL/DAY 13)Tne installer shall verify the location, quantity and elevation of the sewer - lines exiting the dwelling"rior to the installation. . I SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting Title V requirements. ' GAL/DAY AY x 2 DAYS - GAL j D 4 tt} USE (�bO GALLON SEPTIC TANK �.,DW&OC/ tfemw, iwj �dkpeo) 1 { f OIL At350RP ON7SYBTEI� jk\ Fit I DE AREA: `Z��J G.,�j x �� �� I�-I �� DAVID y EOTTOM AREA: s B. L .� MASON m 1 0 ,p�No-1066 SEPTIC SYSTEM SECTION Ale. Li Id 0 IO I`I 1�,5 �A J'�10�� 7.", IP GAL � � g lI I�YY 0 V3 , SEPTIC TANK i o 25 x12,� t 11J ) _ _�,_� � _____-�_--��� SITE AND SEWAGE PLAN II / _...���-UO LOCATION .- � ` boU , PREPARED FOR : �Azpl\q1� P O 0. �...�-✓ SCALE: z \ DAV I D B . MASON � DATE: I I 1 \ DRC ENVIRONMENTAL DESIGNS u EAST SANDWICH . MA Uj --- BATE HEALTH AGENT ( j Q$ ) g 3 3- 2 I 7 Z 7