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Home My WebLink About0193 DROMOLAND LANE - Health 193 DRIMOLAND RD., BARNSTABLE _•� - A=335.085 60 , a I ^ fi n -— " - � Wiz-:_•,_�., �. „ ° n .. • a _.� .. ... - -. ,. � -..t o t ,, . ..- .. n .. � .. `' � � is .. jI y a. r Commonwealth of Massachusetts's ip Title 5 Official Inspectlon Form 7 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 193 Dromoland Lane f Property Address Lucinda Killion , Owner Owner's Name Information is Barnstable MA 02630L " required for every 11-20-19 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. OF Important:When filling out forms A. Inspector Information- �,�a,�•� � z;'• •. ti on the computer, =gr JAMES u' use only the tab James D.Sears key to move your Name of Inspector v cursor-do not Y Ar '• use the return CCom�aW1 enterprises �i' �0 \ key. Company '�ti��c�R�Ft G ``a 153 Commercial Street ;,Sp ��`�� ICE Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector In full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1, ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11-20-19 pectoes Signature Date- C The system inspector shall submit a copy of this Inspection report to the Approving Authority(Board A of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer,:if applicable, and the approving authority. - Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. 15insp.doc•rev.7126IM18 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 l Z a5ed xe: dH W 2 6 OZ 6Z AON Commonwealth of Massachusetts , Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 193 Dromoland Lane`. , Property Address Lucinda Killion Owner Owners Name information is required for every Barnstable MA 02630 11-20-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary. Inspection Summary: Complete 1, 2, 3, or 5 and all of and 6. J 1) System Passes: k ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are. Indicated below. Comments: , The system is a 1500 Gal.Tank D Box and two chamber's i - 4 2) System Conditionally Passes: . R ❑ 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 theboard 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): 15insp.poc-rev.7/2 612 0 1 8 r Tide 5 Oftial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 ZZ abed XeJ dH.6b:2 61,0Z 6Z AoN Commonwealth of Massachusetts if Title 5 official Inspection Form ( 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f, 193 Dromoland Lane Property Aodress Lucinda Killion Owner Owner's Name information is Barnstable MA 02630 11-20-19. ' required for every " page. City/Town State Zip Code. Date of Inspection C. Inspection Summary (cost.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumpslalarms not operational. System+will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high'static water level In the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ` ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): - ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ IN, ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,' t - safety and the environment: ISlnep.doe•rev.7126/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal Syslem•Page 3 of 16 £Z a5ed xej dH 6t7:2.. 660Z =2 .^oN Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 193 Dromoland Lane Property Address Lucinda Killion 1 Owner Owners Name information is Barnstable MA 02636 11-20-19 required for every ' page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) Cesspool or privy.Is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. - ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well r ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"": Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no.other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4)' System Failure Criteria Applicable to All Systems, ' You must indicate"Yes"or"No"to each of the following.for all inspections: NYes No µ - ❑ ® Backup of sewage into facility or system component due to overloaded or. clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc rev.712612018 Title S Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 18 bZ a5ed xeJ dH 69:62 660Z '.l.Z AON c Commonwealth of Massachusetts : p Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r • T193 Dromoland Lane Properly Address Lucinda Killion Owner Owner's Name Inform required r e Barnstable MA 02630 11-20-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static,liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in is less than 6"below invert or available volume is less than day flow ACACHiric ❑ ® Required pumping more than 4 times in the last-year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® -Any portion of the SAS, cesspool or privy is below high ground water elevation. ® _Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of.a,cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.', 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either'yes" or"no"to each of the following, in addition to the questions in•Section CA. Yes No ' ❑ the system is within 400 feet of a surface drinking water supply ❑ the system is within 200 feet of a tributary to a surface drinking water supply . ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 5Z a6ed X J dH 09:2 660Z 62 AoN N Commonwealth of Massachusetts Title 5 Official Inspection Form v� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �4 193 Dromoland Lane Property Address Lucinda Killion Owner Owner's Name information is required for every Barnstable MA 02630 11-20-19 . page. City/Town State Zip Code Date of Inspecdon C. Inspection Summary (cunt:) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no" for each of,the following for alf,inspections: - Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks) ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? E ® 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)] z 6insp.doc r rev.7/26018 Tibe 5 Official Inspection Form:subsurface Sewage Disposal System•Page 8 of 18 9Z a5ed xej dH 652 660Z 62 AON Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Dromoland Lane Property Address Lucinda Killion Owner Owner's Name information is required for every Barnstable MA 02630 11-20.19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions.: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 15DO Gal.Tank D Box and two chambers. Number of current residents: -2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No. If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2018-94,00OGals 9 ( Y 9 (gpd);) 2019-91,000 Gals Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date 15insp.doc•rev.M612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 LZ abed xe j dH 1,9:2 6 60Z I,Z AON I Commonwealth of Massachusetts ` Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 193 Dromoland Lane .1 - Property Adoress Lucinda Killion Owner Owner's Name -< information is required for every Barnstable MA 02630 11-20-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 2. Commercial/industrial Flow Conditions: Type of Establishment: rt Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seatslpersons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present?L El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, K available: Last date of occupancy/use: - Bate _ Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No r If yes,-volume pumped; gallons Now was quantity pumped determined? Reason for pumping: - t5insp.doc•rev.7/262018 Tille 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of is - gZ abed xeJ dH 65 6Z •6 60Z 6Z: AoN Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Dromoland Lane - `� Property Address Lucinda Killion Owner Owner's Name information is required for every Barnstable MA 02630 11-20-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank;distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (Yes or no)(if yes, attach,previous inspection records if any) ❑ InnovativelAlternative 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 IfA system by system operator under contract ❑ Tight tank.*tach a copy of the'DEP approval. ❑ Other(describe): r P Approximate age of all components, date installed (If known)and source of information: 1998 Permit #98- 236. Were sewage odors detected when arriving at the site? : ❑ Yes ® No 5. Building Sewer(locate ori'site plan): Depth below grade: 26" 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.): Pipeing is 4" PVC SCH-40. t5insp.doc•rev.712BJ2018 Title 5 Official Inspection Form:Subsurface Sewage Dispose,System-Page 9 of 18 6Z abed xed dH 65 2 6 60Z 6Z AON c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 193 Dromoland Lane v, Property Address Lucinda Killion Owner Owner's Name ' information is required for every Barnstable MA 02630 11-20-19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 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: 1500 Gal. Precast H-10 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 27" 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 17" 7 How were dimensions determined? Asbuilt-Plan-Tape Sludge'Judge Comments (on pumping recommendations,'iniet and outlet tee.or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank ank cover's at 16". In and outlet tee's. No sign of leakage or over loading._ t5nsp.doc rev.712612018 Title 5 Official inspection Form:Subsurface Sewage Oisposal System Page 10 of 18. v 0£ abed xed dH 6S 6Z 660E 6Z AON Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Dromoland Lane Property Address Lucinda Killion Owner Owner's Name information is required for every Barnstable MA• 02630 11-20-19 page, City/Town State Zip.Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade; feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness. _ Distance from top of scum to top of outlet tee or baffle Distance from bottom of.scum to bottom of outlet tee or baffle - Date of last pumping: oats Comments(on pumping recommendations, inlet and outlet tee or baffle condition,:structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 1 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on she plan): Depth below grade: Material of construction: r ❑ concrete ❑ metal ❑ fiberglass ❑'polyethylene ❑ other(explain): p Dimensions; py w. 4 Capacity: gallons " Design Flow: gallons per day l5insp.doc rev.7/2612018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 a 6£ a5ed xed dH Z56Z 61,0Z 6Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 193 Dromoland Lane Property Address Lucinda Killion Owner Owner's Name information is required for every Barnstable MA 02630 11-20-19 page, City/Town State Zip Code' Date of Inspection D. System Information (cont.), 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: pate Comments(condition of alarm and float switches,etc.): `Attach copy of current pumping contract(required). Is copy attached? . ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 is 16"xl 6'4 Below grade w/two line's out, Box is clean and solid w/no sign of over loading, or solid carry over. - 15in'sp.doc rev.712612018 Title 5 Of vial Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Z£ a5ed xe� dH Z9:2- 660Z I•Z AoN Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Dromoland Lane Property Address Lucinda Killion Owner Owner's Name information is required for every Barnstable MA 02630 11-20-19 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.): " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: t ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovativelattemative system Type/name of technology: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 66 a5ed xed dH Z9:2 660Z 6Z AcN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �qw, 193 Dromoland Lane Property Address Lucinda Killion Owner Owners Name information is required for every Barnstable MA 02630 11-20-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r 11. Soil Absorption System(SAS)(cont,) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is two 500 Gal. Dry well chamber's w14' stone.Camera out lines and prob area. No sign of over loading ,or solid carry over or holding water. 12. Cesspools (cesspool must be pumped,as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer, Depth of scum layer A x 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.) f ` t5insp.tloc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 trE a5ed xed 'dH Z942 660Z 6Z AON Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Dromoland Lane L Property Address Lucinda Killion Owner Owner's Name information is required for every Barnstable MA 02630 11-20-19 per. City/Town State Zip Code Date of Inspection D. System Information(cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure,;level of ponding, condition of vegetation, etc.): t5insp.cloc-rev.7/2812018 Title 5 Official Inspection Form:Subsu,tace Sewage Disposal System-Page 15 of 18. g& abed �' xed dH Zg:2 660Z_ LZ AON Commonwealth of Massachusetts . Inspection Form Title 5 official Ins ect o � p w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Dromoland Lane `J Propdrty Address Lucinda Killion Owner Owner's Name Information is Barnstable MA 0263D 11-20-19 required for every — page, citylrown State Zip Code Date of Inspection D. System Information (cont) 14. Sketch Of Sewage Disposal System: Provide a view cf 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; i 2- - AL ' 2 _ yi'<<i ( _ y 00, t5irle•3n3 Tu a 5 Qrf Ciel hepepi0n Farm 8u5sAw9 Seweps Oisposal System•Pop 15 o1 17 96 abed Xed dH ZS:2 660Z .tZ AON I' Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Dromoland Lane Property Address Lucinda Killion Owner Owner's Name information is required for every Bamstable MA 02630 11-20-19 par, City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: >` ❑ Check Slope - ❑ Surface water ❑ Check cellar ❑ Shallow wells 15' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record w If checked, date of design plan reviewed: 11-24-99 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: T.H. on Design plan - 11-24-99 15'no G.W.; Bottom of leaching at 6' below grade. Bottom of leaching at 9'above T.H. Depth. . Before filing this Inspection Report, please see Report Completeness Checklist on next page. Mnsp.doc•rev.712GM18 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System-Peg e 17 oi'IB L£ a5ed = xed dH Z562 61,0Z I,Z ^oN Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u ' 193 Dromoland Lane Property Address Lucinda Killion Owner Owner's Name information Is required for every Barnstable MA 02630 11-20-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form Inclusive of: ` ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3,or 5 completed as appropriate r 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to'high groundwater included GRAD£ fir �fAtrfirt�� is . Y No r. �.(✓r r . t5insp.doc•rev.712512018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 18 8£ a5ed xeJ did £S:2 660Z I,Z 'AON Commonwealth of Massachusetts' - Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Drumoland Lane, Barnstable M 335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name information is 193 Drumoland Lane, Barnstable MA 02630 July 10, 2013 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. .4•. - Important:When filling out forms A. General Information - on the computer, - use only the tab 1 Inspector: key move your . • l//)V cursor-do not Troy Williams f use the return .Name of Inspector • -., ' key. Troy Williams Septic Inspections Icy Company Name 19 Hummel Drive Company Address South Dennis MA 02660 Cityrrown State Zip Code (508)385 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function'and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: - r� 0^.Passes .�• ❑ Conditionally,Passes �_ : :' ❑. Fails - ❑ Needs Further Evaluation,by the Local Approving Authority, • o ` . . July 10, 2013 Insp or's Signature -'Date T tern inspector shall submit a copy of this inspection report to the ApprovingAuthority(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. l5ins-3A3 ' title 5 Official InspeTF ..rface Sewage Disposal System•P.age 1.of 17 ti e Commonwealth of Massachusetts Title 5 ofii:icial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner. Owner's Name information is required for every 193 Drumoland Lane, Barnstable MA 02630 July 10, 2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont).. Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ° ® I have noffound any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. ems; 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. ccY -. F ❑ Y ❑ N ❑ ND(Explain below): t5ins-3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 2 of 17 - s Commonwealth of Massachusetts Title 5 official Inspection Form' '. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name information is 193 Drumoland Lane, required for every Barnstable MA 02630 .July 10, 2013 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.. t. . 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 El' .ND (Explain below): ❑ obstruction is removed $' ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): Y ❑ 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 2 ❑ 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °e 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name information is every 193 Drumoland Lane, Barnstable MA 02630 Jul 10, 2013 required for eve y 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 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. ❑ 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 %day flow t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I� ` Commonwealth of Massachusetts Title 5 official Inspection Form : Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name , information is required for every 193 Drumoland Lane, Barnstable - MA 02630 . July 10, 2013 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 El ® 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: ❑ ® � y 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 thari 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [Phis 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- 11 ® • 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 drinking4ater supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered'a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large Y system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.,7he 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 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name information is 193 Drumoland Lane, Barnstable MA 02630 July 10, 2013 required for every page. Citylrown 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? ® 0 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 Title 5 official Inspection (Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner owner's Name information is required for every 193 Drumoland Lane, Barnstable MA .02630 • July 10, 2013 page. Cityrrown State Zip Code = Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder?'- ❑ 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 ears usage d 12=58,000 gals. 9 ( Y 9 (gP )) , 11=54,000 gals. Detail Sump pump? Q _ ❑ Yes ® No occupied Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A` N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow,(seats/persons/sq.ft., etc.): w N/A Grease trap present? s. ' ; El Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A 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 V.y�. 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name information isequired for every 193 Drumoland Lane, Barnstable MA 02630 July 10, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): NIA General Information Pumping Records: ' Source of information: Last pumped on 6/7/06 per info from owner. 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 Cl 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-3113 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 8 of 17 L - t Commonwealth of Massachusetts f lugTitle 5 official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Drumoland Lane, Barnstable M -335 - P-085 Property Address Theodora& Blair Perry " Owner Owner's Name information is every 193 Drumoland Lane, Barnstable MA 02630 July 10 2013 required for eve , page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank, d-box and leaching were installed on 10/7/98 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18"+ Depth below grade: feet Material of construction: , ❑cast iron -®40 PVC. ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: feet - 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: 6'X10.5'X6' 1500 gallon 411' Sludge depth: } t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 official Inspection Form Subsurface Sewage Disposal`System Form-Not for Voluntary Assessments "< 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name information is required for every 193 Drumoland Lane, Barnstable MA 02630 July 10, 2013 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 Scum thickness thin layer 611 Distance from top of scum to top of outlet tee or baffle r Distance from bottom of scum to bottom of outlet tee or baffle . 14" How were dimensions determined? probe/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.): Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins-3/13 Title 5 official Inspection Fond:Subsurface Sewage Disposal System•Page 10 of 17 'f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Drumoland Lane, Barnstable M-335 ,P-085 Property Address Theodora& Blair Perry Owner Owner's Name information is every 193 Drumoland Lane, Barnstable MA 02630 Jul 10, 2013 required for eve y page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) r 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: N/A Material of construction: #' ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: N/A , Capacity: N/A gallons Design Flow: gallons per day Alarm present: ❑,Yes ❑ No Alarm level: N/AY Alarm in working order: :0 Yes ❑ No Date of last pumping: N/A • Date Comments(condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner owner's Name information is d L l 193 Drumoanane, required for every Barnstable MA 02630 July 10, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order with equal distribution to outlet lines. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A *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 Title 5 Official inspection form = Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - ,z - 193 Drumoland Lane, Barnstable .{M-335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name information is 193 Drumoland Lane, Barnstable MA 02630 ' July 10, 2013equired for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type. - - • . '_�e� �. • - ❑ leaching pits :, number: ® leaching chambers number: 2 4'-off stone with . t ❑ leaching galleries number: 25'X 13'X 2' ❑ leaching trenches number, length: . ❑ leaching fields number, dimensions: _ ❑ overflow cesspool number. f , _ ❑ innovative/alternative system Type/name of technology: Comments(note conditiomof soil, signs of hydraulic failure, level of ponding, damp soil, condition of. vegetation, etc.): Soil was sandy.Water was found to be low in chambers at the time of inspection. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): N/A Number and configuration. Depth-top of liquid to inlet,invert R N/A N/A Depth of solids layer N/A Depth of scum layer r Dimensions of cesspool N/A I Materials of construction N/A 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Drumoland Lane, Barnstable M--335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name information isequired for every very 193 Drumoland Lane, Barnstable MA 02630 July 10, 2013 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.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of.hydraulic failure; level of ponding, condition of vegetation, etc.): N/A t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts lugTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name ` information is required for every 193 Drumoland Lane, Barnstable MA 02630 July 10, 2013 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 Fro N L L__j A Y S 2.3 " . r . 'Z .• �IZ'�n � � �j Syr, L/ t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form J Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 193 Drumoland Lane, Barnstable M=335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name _ information is required for every 193 Drumoland Lane Barnstable MA 02630 July 10, 2013 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Site Exam: ® Check Slope N ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 13.0'+feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 10/24/89 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: AIW 247 Zone B 22.4' 2.3'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 180". Hand augered 4' below bottom of leaching with no water found at a depth of 9.5'. Groundwater adjustment at the time of inspection was 2.3'. Bottom of leaching at 5.5'was found not to be located in the high groundwater elevation at the time of inspection. t Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form i Subsurface Sewage Disposal System Form-Not for'Voluntary Assessments 193 Drumoland Lane, Barnstable M-335 P-085 Property Address Theodora& Blair Perry Owner Owner's Name information is 193 Drumoland Lane, Barnstable- MA' 02630 Jul 10 2013 required for every Y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B,.C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 1� } t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for.every Marstons Mills Ma 02648 12/12/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I use only the tab 1. Inspector: Y move Y key to our lY cursor-do not Richard M. Capen use the return Name of Inspector key. Capewide Enterprises Company Name 153 Commercial St. Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-477-8877 SI 13385 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 I 12/12/12 Inspecto's ignature 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•11/10 Title 5 Official Inspecti JFS.b surface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1567.Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 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 ❑ ® 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 '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. CitylTown 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes.if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health,to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of.a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of apublic 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Y Title 5-Official- Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. Cityrrown 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 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? ® ElWas 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330gpd t5ins•11/10 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 ,M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 20 cZ Z� Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. Cityrrown 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: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth.of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12. page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: original system Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints,venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, Fist age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons 4 Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 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 2.5 Scum thickness 2 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 10.. How were dimensions determined? opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was intact and in good condition. 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 t5ins•11/10 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 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. City/Town 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: Material of construction: El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Fora Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments ^M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is r n required for every M a sto s Mills Ma 02648 12/12/12 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.): Box was functioning as intended. Da-box was video inspected and found to be soild with no rot, no ins of past hydraulic overloading 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 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 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. Cityrrown State Zip Code Date of Inspection D. System Information.(cont.) 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.): Pit was video inspected and found to have 5' of available leaching with no signs of past failure 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 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: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 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 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 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 (3 o C 0 A _ C Zc.. A — D 3L( A - � 2 � L C Liy b � f �I �3 64 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. CitylTown 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: 20+ 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: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps Before filing this.lnspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1567 Race Lane Property Address Ben Canavan Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/12/12 page. CityTrown State Zip Code Date of Inspection E. Report Completeness Checklist Z. inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1-3 TOWN OF BARNSTABLE � LOCATION Loq Q "Deo,+oLao4 aJ SEWAGE# �z3� VILLAGE ASSESSOR'S MAP & LOT- INSTALLER'S NAME&PHONE NO. (DZ c-d q19-30L— SEPTIC TANK CAPACITY ISov &AL— LEACHING FACILITY: (type) �Z� �° 2Al OkAMUVS (size) 13t( 2� NO. OF BEDROOMS BUILDER OR OWNER yi\ rL�> PERMTTDATE: COMPLIANCE DATE: Leo a '7 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- 9 d 3 y I lz zo Z 10 Z3 a� y zy ys .. , o 9 6, No. Fee a 7 7,6"' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0ppiicatiou for Miquar 6petem Conotruction Vermit Application for a Permit to Construct(`Repair( )Upgrade( )Abandon( ) VComplete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. C-0 mrn4 a.L i b N1✓>_1f v,� X'o� ZV EUPLf_41 Assessor's Map/Parcel 3'3s/,8 5 '7/Q 8 j1 r/�104E �C Installer's Name,Address,and Tel.No. _ Designer's Name,Address and Tel.No. 7 5-- 6 7 3 Sr .JOB v f6lfJa�4 � -60 eu � v/155ec. 3d k5 . Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(At) Other Type of Building 41AfA FM024 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33d gallons per day. Calculated daily flow 353 gallons. Plan Date Y_16--ff Number of sheets I Revision Date Title IOT /7 �W V dL6 1ADO /2 A CO 1W W.4 C0 AD Size of Septic Tank � /500 Type of S.A.S. A-�Description of Soil /� opg4_ PLA 4,/ Nature of Repairs.or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme 1 Code and not to place the system in operation uTaC/e;*ficate of Compliance has been is and ofHe Signed Date Application Approved by Date Application Disapproved for M following reasons Permit No. — 4. Date Issued 'D tip No. V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS i Zipprication for Migaal *p5tem Construction Permit , Application for a Permit to Construct( V Repair( )Upgrade( )Abandon( ) &O(omplete System ❑Individual Components Location Address or Lot No. 1473 l71Z,6)M 0 L�q V A R"D Owner's Name,Address and Tel.No. CU/Y�iYtR��J?> f/ENity-f 4!ogo 4vi54.�OL"SA2 Assessor's Map/Parcel :335/00 5- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 75'd Q 3 JUE 16/ryvo _ 7FF Type of Building: Dwelling No.of Bedrooms Lot Size y5:at16 sq. ft. Garbage Grinder(A10 Other Type of Building LGdd A No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3V gallons per day. Calculated daily flow 3-53 gallons. Plan Date q—/Q " Number of sheets / Revision Date _'Title 407 /7 D2 UA04AAlt) R Z% C-t)MI 4 6J'!f 1A < Size of Septic Tank p.- /S� Type of S.A.S. Description of Soil /�5 - P4'A� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme 1 Code and not to place'the system in operation until a Cert' m- cate of Complia7e,has twee-i su is d of Pe �-� Signed r. Date S Application Approved by Date N - J S- Application Disapproved for the following reasons - - - * Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( i-)Repaired( )Upgraded( ) Abandoned( )by at _# /93 -D" QL19 ND RD WIP has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9,S-13/_-, dated Installer Designer The issuance of thi=—I shall not be construed as a guarantee that the syste ill function as designed. Date '7 Inspector No. FeeInin> THE COMMONWEALTH OF MASSACHUSETTS a PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwiopogaf*p5tem Construction Permit Permission is hereby�ranted to Construct( )Repair( )Upgrade( )Abandon( ) System located at .F� /93 _bX U 6464G09 t/D Ae and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction musube completed within three years of the date of this permit. - Date: Approved by TOWN OF BARNSTA.BLE LOCATION Lag 11 Oeo�,OLA04 SEWAGE # VILLAGE C v rb, ASSESSOR'S MAP& LOT ,� INSTALLER'S NAME&PHONE NO. C-y SEPTIC TANK CAPACITY - 1660 A�- LEACHING FACILITY: (type' (size) 13Y Z,S NO. OF BEDROOMS 3 BUILDER OR OWNER �a�5 PERMITDATE: /- _COMPLIANCE DATE: I to 7 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 YZ Q A (� 3 y 11 Z Z o 5 c6 3 1 c) z co o� y Zy �15' S Z£S S3 (0 3 3 53 �G 4 ti TEST HOLE LOG DATE: 0--lbew- Z4 1 kcj*j 5 _ qAq(_ 1 a�� \ w/ / t� SOIL ESALUUAATOR:F-V t::.� WIT 60 7 tt C P1 G PERC RATE: < J/1 2 M v .3 L-OT 17 lob / '45,zic- IC-70uLO a.oia,r( r,5, \ g a �.f7 S�iP'�OI�... �A �A A ° � tj 0 /� l 570 Izo $:I1"x s4ejo Fri sAeb 03 ' � p� Gw v/ I DESIGN DATA DAILY FLOW: (3)BDRMS.z 110 GPD= 33o GPD SEPTIC TANK: 3go GPD z 200%= 64-0 GPD USE: 156c, GALLON PRECAST SEPTIC TANK LEACHING FACILITY: USE: 1 Ar 5 APACI : 4 � �g �" _ t C TY o ,u 4,.�►� 7¢ F4 V �. d.- l SIDEWALL:,7Gx Z I o, 1 tea. 1 b11-14 GI rJ Sq tt� BOTTOM: 13,Y.ZS x o,-7j--Z¢o,s / TOTAL: 355, o Go / 3 h jk_+ M � a.4 / G�,o O �f,o 0��r GZ,Z �g . 631 S 4Joor> ic�r-( 18� 61.0 .� 1,^ �.,, .. - ., ., 2oG .C .o --- - gyp• P�)iA OF Mqs� 9c NOTES: o� BRAMAN y1Gj1 1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. o uvn c", 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION" v No.326B6C y BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A �y GARBAGE DISPOSAL b 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2•LAYER OF JA•PEASTO OVER 3/41-1 1/2'WA9lD3D STONE ALL ' AROUND TOP OF FOUND. y T .. @ EL 6,7,So f fo• f,• G3'p1' Gt.So r $��Cr-( - 1✓t-.60,o a 1 5 SEPTIC SYSTEM PROFILE SITE SEWAGE ]PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION Z2, �� r-!4 OF ALL UTILITIES,ABOVE AND UNDERGROUND.PRIOR ?LAA0 _ 3 �� TO ANY EXCAVATION OR CONSTRUCTION. p 3 A-_E MAA7 535 05 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH 1 PREPARED FOR 310 CMR 1&00;TITLE V. � 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION. DATE: AIt_ Iv,1 $ SCALE: I = � 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS f WELLER & ASSOCIATES . 1645 FALMOUTH ROAD CENTERVILLE, MA. .02632 TEL: (508)775-0735 FAX: (508) 775-0754 - s Anunvlr n say. _ TEST HOLE LOG ,,,/ DATE: G�'rD� 24, 1�1 25 ��' l= QAj(- ►O T w �. % �}- SOIL EVALUATOR:F-tP' C $L.. G7� I WITNESS: $ � / PERC RATE: �Z M vJ/ � 1� 3� 1 �Z 17, uLoofl �,s.o oov e4W40 Mom• G� ►�� w1D ,o 2 1 »4JW sa.b f i ,o ISo" 53,0 �0 b 0 . o I DESIGN DAT DAILY FLOW:(3)BDRMS.z 110 GPD= 330 GPD ♦„ / ' SEPTIC TANK: �yo GPD z 200%= 64-v GPD USE: (5do GALLON PRECAST SEPTIC TANK LEACHING FACILITY: -6 / USE:(Z)5 x8 x2 5 4wv . V2� N6(E: qht�/�, 9 ��4�� of�o►.�� Ar 5 tzg }Y l CAPACITY: J* �AG1 a•� e'w� --� / d- / SIDEWALL: 7!.x.Z x 0,-7¢ = 11Z,S �- tAtIq 4a3avva i `-/ BOTTOM: 13'x 2SX o,7 Z o,s ` TOTAL: 353, o _ �o3 N I CF G ,a o 66,0 0 boob LOAN �M G3,S WOO-2 Lo-r'{ 6110 OF gsf9 M H�Yc „ O� DANIEL E. �y NOTES: 5�.0 15(p ri .o 13Z BRAMAN t. ALL PIPE'TO BE 4"DIA.SCH 40 PVC. - Sp1.1rj o CIVIL 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION ti. No.32606C y BOX, 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN �l o �L>r ►JGo1�►7� {�►) 6"OF FINISH GRADE. omw 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL g 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEL 2'LAYER OF 31S*PEASTONE OVER 314'-I In*WASHED STONE ALL AROUND TOP OF FOUND. @ EL. KP7,r2o 10' 14' T�' �• �2.7 G3,co GZ Gt.So GZ 18 I `, 150T crt �,./o.oa a�..G.•o !�(o e SEPTIC SYSTEM PROFILE , 4 SITE ^- SEWAGE .PLAN � GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION ZJ71 OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR 3 s+ TO ANY EXCAVATION OR CONSTRUCTION. s Hai 535 FNr4rA, $5 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 16.001 TITLE V. 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE ---�G✓S/, � et,-�,Cc > 4:e: ClL. DETERMINATION. DATE: AIL- la,lle)je- SCALE: I N 4. ALL DISTURBED AREAS TO LOANED AND SEEDED. S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. WELLER & ASSOCIATES 1645 FALMOUTH ROAD ;CENTERVILLE, MA. .02632 •` �. ,TEL: (508)775-0735` FAX: (508)775-0754 a f TEST HOLE LOG DATE: a—fbeW_ z}, IG$'j 25 SOIL EVALUATOR:Ev C L.. G750 I WITNESS: 60 _ �4, --7 PERC RATE: <2.MuJ/h•3 61 e-AW Hsu, M410 fd-, `" G1.0 rI / i I I , ; 5 c�yr1►X �� SB.o A1?o o + P 1 AI C�e o .0 op DESIGN DATA dR¢ I ,� ;: DAILY FLOW: (3)BDRMS.z 110 GPD=33o GPD / + SEPTIC TANK. 330 GPD z 200%= 6,Go GPD \ `✓ �, 1 ' USE: 15bo GALLON PRECAST SEPTIC TANK LEACHING FACILIT �� USE:(Z) x8 0-Z S� - VZ(-1 961i�-: 415:N Nk_w AW IM p�z� is /4 r4jVwAL r—¢- A-5� s ' _ CAPACITY: FACI Ll 4 J'-IE(x4cE / tJ- / , SIDEWALL: 7( x Z x o,"7¢ = I IZ,S k41 p GJEXV l 54kr� j BOTTOM: f TOTAL: . Go / 3 Z,5 boob l.oaM rJ �M G3�S oa-> L"� { I$+ G vi 61.0 _ BAH OF�y DANIEI E.Ay NOTES: 61.0 � M .0 13Z' BRAMAN G I. ALL PIPE TO BE 4"DIA.SCH 40 PVC. ►. SAfV G o CIVIL '", 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION y No.32686C y BOX. �F �,� Q 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN NO "4TiP-{Z- IJGoi.�►� {�►> �Q C! T R �4� 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A �y GARBAGE DISPOSAL _ b - 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEL 21 LAVER OP"I PEASTONE OVER 3/4•-I III,WASIRD STONE ALL AROUND TOP OF FOUND. EL. (o'r So to, I,. a P1•G�.o GZI GZ.C$ lvZ,o� SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN e GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION L&-F 17 D%eor1 OLA%X� ZCZ GI,4r1rfAc�►.1►17,:.�°tic . OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR 'FLA" VcC*- 3 6' rpAet1i 610 TO ANY EXCAVATION OR CONSTRUCTION. A� rtAf 535 O3 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR IL 00i TITLE V. 3. THIS PLAN IS NOT O BE USED FOR PROPERTY LINE ---.00G,�/,��r' � ,C'0 GcJ��tJ.OG Cmez DETERMINATION. DATE: A f wL_ to,1419$ SCALE: I"a 4-o' 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. WELLED & ASSOCIATES . 1645 FALMOUTH ROAD CENTERVILLE, MA. .02632 ' TEL: (508)775-0735 FAX: (508)775-0754