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HomeMy WebLinkAbout0009 HANSON LANE - Health Hanson Lane Barnstable F/R -�- A.= 298. 074 I +a TOWN OF BARNSTABLE a00 ®!/ LOCATION ` soh iC�.� SEWAGE # VILLAGE UIZ44 ASSESSOR'S MAP &c LOT INSTALLER'S NAME'&PHONE NO. '��e SEPTIC TANK CAPACITY � LEACHING FACILITY: (type) 6.�ZA3 (size) /A�' A;�`Z NO. OF BEDROOMS BUILDER O �' PERMITDATE: ` `Z 6 —COMPLIANCE-DATE:— Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of LeachingTacility 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 leachi4facility) Feet Furnished by ca�� x r S A Commonwealth of Massachusetts' f Title 5 Official Inspection Form' 4 - Subsurface Sewage Disposal System_Form-Not for Voluntary Assessments °f 9 Hanson Lane,,Barnstable s .M -298 P-074 • Property Address Mary Nowd Owner Owner's Name information is required for every 9 Hanson Lane, Barnstable MA 02630 . - July�10, 2013 - page. CItyrrown State Zip Code Date of Inspection • Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: V key to move your •�(� ,� cursor-do not Troy Williams t y use the return key. Name of Inspector Troy Williams Septic Inspections "II Company Name 19 Hummel Drive Company Address *• South Dennis *. MA ., - 02660 City/Town State . . ' "' Zip Code (508)385- 1300' S1682 Telephone Number License Number ' B. Certification o I certify that I have personally inspected the sewage disposal system at this addres and thate information reported below is true, accurate and complete as of the time of the inspection. Thilnsp€dtion was performed based on my training and experience in the proper function and main tenancew on _ sewage disposal systems. I am a DEP approved system inspector pursuant to section 15. 40 - Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes, ❑ Fail M ❑ Needs Further Evaluation by the Local Approving.Authority J July 10, 2013'° 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 -44 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 9 Hanson Lane, Barnstable M -298 P-074 Property Address Mary Nowd Owner Owner's Name information is required for every g Hanson Lane, Barnstable MA 02630" ° July 10, 2013 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: - 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. 11-- 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. Tlie septic tank is metal and over 20 ears old*or the septic tank whether metal or n i p y p ( not) s structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Hanson Lane, Barnstable M -298 P-074 Property Address Mary Nowd Owner Owner's Name information is required for every 9 Hanson Lane, Barnstable MA 02630 July 10, 2013 page. Cityrrown 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 Hanson Lane, Barnstable M-298 P-074 Property Address Mary Nowd Owner Owner's Name information is required for every 9 Hanson Lane Barnstable MA 02630 July 10, 2013 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 E ® 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Hanson Lane, Barnstable M -298 P-°074 Property Address Mary Nowd Owner owner's Name information is required for every 9 Hanson Lane, Barnstable MA 02636 July 10, 2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No i ❑ ® 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.] ❑ Z 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 ❑ 0 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f . N Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..'< 9 Hanson Lane, Barnstable M -298 P-074 Property Address Mary Nowd Owner Owner's Name information is 9 Hanson Lane, Barnstable MA 02630 " July Jul 10 2013 required for every , 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 break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue ® El 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 d x#of bedrooms 330 ( P 9P ) 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 9 Hanson Lane, Barnstable M -298 P-074 Property Address Mary Nowd Owner Owner's Name information is 9 Hanson Lane, Barnstable MA 02630 Jul 10, 2013 required for every Y page. City/Town 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 Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 12=42,000 gals. g ( y g (gp ))' � 11=42,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate 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.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? - - ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "f 9 Hanson Lane, Barnstable M-298 P-074 Property Address Mary Nowd Owner Owner's Name information is 9 Hanson Lane, Barnstable MA 02630 Jul 10, 2013 required for every Y page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): N/A General Information Pumping Records: Source of information: Last pumped on 1/7/03 per info from BOH. 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts ID Title t e 5 Official Inspection p on Form Subsurfac e Sewage Disposal System Form Not for Voluntary Assessments _ 'l 9 Hanson Lane, Barnstable Property Address M -298 P-074 Mary Nowd Owner owners Name information is required for every 9 Hanson Lane, Barnstable MA 02630 July 10, 2013 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: D-box and leaching were installed to existing tank(3/17/81)on 1/7/03 per compliance Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1811+ 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: 10" feet Material of construction: ®concrete ❑ metal ❑fiberglass 9 .❑ 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: 5'X9'X6' 1000 gallon Sludge depth: 4" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 it N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Hanson Lane, Barnstable M-298 P-074 Property Address Mary Nowd Owner Owners Name information is required for every 9 Hanson 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 21811 Scum thickness thin layer 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 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.): Concrete inlet and concrete 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 Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Hanson Lane, Barnstable M -298 .P-074 Property Address Mary Nowd Owner Owner's Name information is required for every 9 Hanson Lane, Barnstable MA 02630 _July 10, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ 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 Tide 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 9 Hanson Lane, Barnstable , M-298 P-074 Property Address Mary Nowd Owner Owner's Name information is required for every 9 Hanson Lane Barnstable MA 02630 July 10, 2013 page. Cityrrown 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. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 9 Hanson Lane, Barnstable M -298 P-074 Property Address Mary Nowd Owner owner's Name information is Y 9 Hanson Lane, Barnstable MA 02630 Jul 10 2013 required for every , page. Cityfrown State. Zip Code Date of Inspection D. System Information (cont.) , Type: ❑ leaching pits number: ® leaching chambers'- number: 2�-500 gal. with 4 of stone ❑ leaching galleries number: 25'X 12'X 2' ❑ 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.): Soil was sandy. Chambers were found with 3"of water present with walls found clean above water level. 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): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A. Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Foam: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 9 Hanson Lane, Barnstable M -298 P-074 Property Address Mary Nowd Owner Owner's Name information is g Hanson Lane, Barnstable MA 02630 July 10, 2013 required for every page. Cityrrown 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 N/A Dimensions 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 Form: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 9 Hanson Lane, Barnstable M-298 P-074 Property Address Mary Nowd Owner Owner's Name information is 9 Hanson Lane, Barnstable MA 02630 Jul 10 2013` required for every y 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 2 Lt R e • � 4 ' t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .yy 9 Hanson Lane, Barnstable M-298 P-074 Property Address Mary Nowd Owner Owner's Name information is required for every g Hanson Lane Barnstable MA 02630 July 10, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: 1/9178 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 C 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 12.0'. 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. 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Hanson Lane, Barnstable M-298 P-074 Property Address Mary Nowd Owner Owner's Name information is g Hanson Lane, Barnstable MA 02630 Jul required for every Y 10, 2013 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C,'D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15"or attached in separate file t5ins-3/13, Title 5 Official inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 { r No? 2U0 O { Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: / Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Zigog impotent Construction Permit Application for a Permit to Construct( )Repair( Upgrade( ` )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. iiso n Aq vW Owner's Name,Ad s and Tel.No. Assessor's Map/Parcel &-�s� 1rX-r�rr®41 M 2<'e- \ 7 C h 4.- Installer's Name,Address,and Tel.No. Designees ame,Address an Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Q Design Flow C3 gallons per day. Calculated daily flow � �l gallons. Plan Date Number of sheets 1 Revision Date Title ` Size of Septic Tank o 0_0� Type of S.A.S. lZ"lae�� 2T-UN. 7? ` 2 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4 i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issuedby this Board f Signed Date� ! Application Approved by Date / Application Disapproved for the following reasons Permit No. `IbC>3—oft Date Issued qiz 2oo 3- o I l 5v� No: Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppffcation for �Dtzpoe _*potern Construction 3permit Application for a Permit to Construct( . )Repair(VTOU40pgrade( ' )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ons p h h4 Ojw�nneer's Name,Add sand Tel.No. Assessor's Map/Parcel24 Installer's Name,Address,and Tel.No. Designer',,,,Name,Address anj Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder'( Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Q Design Flow "3 1 Q gallons per day. Calculated daily flow 3 47 gallons. Plan Date t Z. o f1 Z Number of sheets l Revision Date - Title Size of Septic Tank 1 0-crU Type of S.A.S. Description of Soil 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this Boar oftH- Signed cam- �1- ��--- - Date OZ Application Approved by ' Date / Application Disapproved for the following reasons F Permit No. 2 bo 3-0".1 4 1 --*,If I D' Date Issued t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS.IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(kXUpgraded ( ) Abandoned( )by \4 VC`L.e" A,,,_�-�i� at 9 t OM.- / L ,--1_� has been constructed i accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2pO3'of 1 dated -7 v 3 Installer �k-c-<<4 Designer The issuance of this permit shall not be construed as a guarantee that the syste:Tn W)ill function designed. Date I �'U Inspector rl'' G�vt ,/b` �. ————— No. 20U 3•— U(( � � � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwiopogal *pgtem Conotruction 3permit Permission is hereby granted to Construct( )Repair( ade( )Abandon( ) System located at '� �'�� �-soy._. `..._� 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:Construcn must be completed within three years of the date of this ( e Date:_ `� ico) 3 Approved by i TOWN OF BARNSTABLE LOCATION �4 SEWAGE # _ VILLAGE `���t J � // ASSESSOR'S MAP & LOT KARR 112 k INSTALLER'S�ANS&PHONE NO. �� K t�pn '7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) _.��ir size oLe Ar NO. OF BEDROOMS BUILDER 01 0 PERMITDATE: t b COMPLIANCE DATE: Separation Distance Between the: Fa Feet. Maximum Adjusted Groundw ater Table to the Bottom of LeachingFacility y Private Water Supply Well,and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by a r f , ('� _ � __ TROY WILLIAMS �� SEPTIC INSPECTIONS TO Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETI'S EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ProperiN Address: 9 Hanson Lane Barnstable,MAC Owner's Namc: MaryNowd Owner's Addres,: 9 Hanson Lane Barnstable,MA 02630 Date of Inspection:• November 8,2002 Q, Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections (( l) Mailing Address: 19 Hummel Drive wJ South Dennis,MA 02660 Telephone Number: (5d8)385-1300 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv�tem Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authow) Fails Inspector's Signature: -Q Date: t t / s /o z The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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. Notes and Comments Aithough system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""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 saute or different conditions of use. Title 5 Inspection Form 6/15/2000 pace I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Hanson Lane Barnstable,MA Owner: Mary Nowd Date of Inspection: November 8,2002 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 y of the failure criteria described in 310 ONIR 15.303 or in 3I0 CMR 15.304 exist. Any failure criteria no valuated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass"section rued to be repl ed or repaired. The system, upon completion of the replacement or repair,as approved by the,Board of 1-1 th,will pass. Answer yes. no or not determined(Y,N,ND)in the for the following statements. if- of determined"please explain. The septic tank is metal and over 20 years old' or the septic tank(whetl metal or not)is structurally unsound,exhibits substantial infiltration or exftltration or tank failure is im 'nent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by th oard of Health. "A metal septic tank will pass inspection if it is structurally sound,n eaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break ou r high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o neven distribution box. System will pass inspection if(with approval of Board of Health): br n pipe(s)are replaced struction is removed distribution box is leveled or replaced ND explain: The syste equired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspecti if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 Hanson Lane Owner: Barnstable,MA Date of Itupection: Mary Nowd November 8,2002 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. L S)'stem N%ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1) that the system is not functioning in a manner which will protect public health,safety and the till,.ronment: _ 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 m sh 2. System will fail unless the Board of Health (and Public Water upplier,if any)determines that the system is functioning in a manner that protects the public healt ,safety and environment: _ The system has a septic tank and soil absorption sy m(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water s ly. The system has a septic tank and SAS an e SAS is within a Zone 1 of a public water supply. The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. - The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. hod used to determine distance **This system passes if a well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile ganic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteri a triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 Hanson Lane Barnstable,MA Owner: Mary Nowd Date of Inspection: November 8,2002 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 clot f)ed 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 L—� P", Liquid depth in emspeel is less than 6"below invert or available volume is less than %2 day flow V Required pumping more than 4 times in the last year 1VOT 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. N/4 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, .vIi Any portion of a cesspool or privy is within a Zone 1 of a public well. 16�& Any portion of a cesspool or privy is within 50 feet of a private water supply well. 1 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 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 forma _`i aj (Yes/No)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 desi 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 ove) yes no the system is within 400 feet of a surface drinking w r supply the system is within 200 feet of a tributary to a face drinking water supply u the system is located in a nitrogen sensiti area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any questi in Section E the system is considered a significant threat,or answered "yes"in Section D above the large sy m has failed.The owner or operator of any large system considered a significant tlueat under Section E o ailed under Section D shall upgrade the system in accor*ce with 310 CMR . 15.304.The system owner shou contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 Hanson Lane Owner: Barnstable,MA Date of inspection: MaryNowd November 8,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the followinu: Yes No ✓ f ..;:-+inu information was provided by the owner. occupant, or Board of I lealth Were any of the system components pumped out in the previous two weeks — Has the system received normal flows in the previous two week period ? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ — Were as built plans of the system obtained and examined?(If they were not available note as N/A) _✓ — Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? _✓ .__ Were all system components,.excluding the SAS, located on site _✓ __ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _✓ _._ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ' The sue and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no ✓ — 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)[31.0 CMR 15.302(3)(b)) 5 i Page 6 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 Hanson Lane Owner: Barnstable,MA Date of inspection: Mary Nowd November 8,20PJ OW CONDITIONS RESIDENTIAL 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): .3 30 Number of current residents: i Does residence have a garbage grinder(yes or no): ,,vo Is laundn on a separate sewage system (yes or no):n__ro [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): ,�& Water meter readurgs, if available(last 2 yearstisage(gpd)): o4-o = b[ oou -t�do c bd-.o t Sump pump(yes or no): No . Last date of occupancy: 0C, T;�d COMMERCIAL/INDUSTRIAL 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 syst (yes or no): Water meter readings, if available: _ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: g, � : ++ ._._S .yy 81Zy 17 r 1/81F 7 Was system pumped as part of the inspection(yes or fro): � p� Yt�..t 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) Tight tank . _Attach a copy of the DEP approval _Other(describe):. Approximate age of all components. date installed(if known)and source of information: IIJ 3 /1-7 frl Were sewage odors detected when arriving at the site(yes or no): Alo 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 Hanson Lane Owner: Barnstable,MA Date of Inspection: Mary Nowd November 8,2002 BUILDING SEWER(locate on site plan) Depth belu%+ grade: 18 "+ Materials of construction: _cast iron ,,/40 PVC ,-_other(explain): Dkianc fron pri%ate 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: /v„ Material of construction:,concrete_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: S `x 9 'k /000 Sludge depth: — 91, _ Distance from top of sludge to bottom of outlet tee or baffle: o? '8'' Scum thickness: 3�, Distance from top of scum to top of outlet tee or baffle: _G Distance from bottom of scum to bottom of outlet tee or baffle: Flow were dimensions determined: )OW 6� . _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): / GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass___Po ethylene_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 outleZ baffle: Date of last pumping: Comments(on pumping recommendations,inletlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leaka ,etc.): 7 Page 8 of I l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 Hanson Lane Owner: Barnstable,MA Date of Inspection:Mary Nowd November 8,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of ins tion)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_ polyethylene other(explain): Dimensions: Capacity: gallons Design Flo%N. gallons/day Alarm present(yes or no): Alarm level:__ Alarm in working or (yes or no): Date of last pumping: Comments(condition of alarm and f) switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: abo„- Comments(note if box is level and distribution to outlets equal,any evidence of solids carrypver, any evidence of leakage into or out of box,etc.): 120 c �n a o c -rbv ..1 f + e� b o /s�I// • t 'I�—�L._Y�? MJ (� _..2 t ✓c.o �c �1_..� JL...0..r h 1 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,con ' on of pumps and appurtenances,etc.): 8 i Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 Hanson Lane Owner: Barnstable,MA Date of Inspection: Mary Nowd November 8,2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits. number: leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comme etc.): nts(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,'i ondition of vegetation, /L/�c�c,�-1.,---- r_.�_ ..�^'K���_{��-✓�'L� I�s J __'.��.„ .M: ,,,�,,.., .� .�_-�_Jl... �o ti. o..'�` �,-� i CESSPOOLS: (cesspool must be pumped as part of inspection)(loc• a on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum la\er Dimensions of cesspool: — Materials of construction: _ Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of aulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: --- — -- Depth of solids: i Comments(note condition of soil,signs of hydraulic f ure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 Hanson Lame Barnstable,MA Owner: Mary Nowd Date of Inspection: November 8,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. r�uUy�r�oh 3� y, 1351(l q C q` P i36x w•� •1'� 2 ' S�h� . � . �p i Page 1 1 of 1 l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: 9 Hanson Lane Owner: Barnstable,MA Date of Inspection: Mary Nowd SITE EXAM November 8,2002 Slope ✓ Surface water Check cellar Shallow wells Estimated depth to ground water i °v feet Adjusted high ground water elevation_^_feet Please indicate(check)all methods used to determine the high ground %%ater elevation: _Obtained from system design plans 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 Flealth-explain: — Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain:- You must describe how you established the high ground water elevation: (« 5_�� G,� /vim F—�6A GrkJ� u u This report has been prepared and the system inspected as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating td the System,the inspection and/or this report. 11 • • - j,1� Ste`.'{ r � a Daft OFFICIAL O M PostageEr u7 Certified Fee F Post 1'S' Return Receipt Fee I� Her R7 (Endorsement Required) Restricted Delivery Fee ? )� � (Endorsement Required) O p Total Postage&Fees $ 4 , y ,a Sent To Mary M Nowd� 0 Street,-Ap—t No,j 1 9 Hanson Lane -- M _City State,Z;P4 Barnstable, MA 02630 Certified Mail Provides: o A mailing receipt v o A unique identifier for your mailpiece � n A signature upon delivery . o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece to Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt,is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,May 2000(Reverse) 102595-99-M-2087 i Town of Barnstable F INE 1p� ►' do Regulatory Services xSTnsLE Thomas F. Geiler,Director BAR9Q, '63. ��� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Mary M. Nowd Date: 8/10/02 9 Hanson Lane Barnstable, Ma 02630 FINAL NOTICE ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE,TITLE 5. Our records indicate the septic system owned by you located at 9 Hanson Lane Barnstable, Ma was inspected on 7/8//97,by Joseph Macomber a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: The wastewater level was over the invert pipe. According to Title V, the owner had two (2) years to repair or replace the system. More than two years has past since the date of this inspection. You were previously notified of the failed septic system. However, the system has not been repaired as required as of this date. Therefore, you are directed to hire a licensed professional engineer (PE) or Register Sanitarian (RC) to design a system that will bring the septic system in compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within twenty-one (21)days of your receipt of this letter. You are also directed to hire a licensed septic system installer to install the system components within forty-five (45) days of your receipt of this order. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings,onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. Failure to comply to this order of the Board of Health, may result in court action against you the owner of this property PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable Town of Barnstable Assessors Division Page 1 of 3 ner Your Location : Home : Town Departments :Administrative Services : Assessors.Division : Property Results <<Back-Forward>> Thursday, May 30,2002 Assessors Division- Property Results Data is based on Fiscal Year 2002 Assessor's Fiscal Year 2002.Assessed.Values database and is provided for information Tax Information purposes only. Sales History Land and Building Description Construction.Details «Search Again Out Buildings.& Extra Features Building Sketch 9 HANSON LANE Map/Parcel/ Parcel Extension: Mailing.Address: 298/074/ NOWD, MARY M. Owner of Record: NOWD, MARY M 9.HANSON LN, Property Location: BARNSTABLE, MA 02630. 9 HANSON LANE Parcel ID:298074 'yv Fiscal Year 2002 Assessed:Values ^Top Appraised Value Assessed Value Building Value: $167,700 $ 167,700 Extra Features: $.2,800 $2,800 Outbuildings: $0 $0 Land Value: $72,000 $72,000 Totals: $242,500 $242,500 Tax Information ^Top Town Tax $2,245.55 Tax Rates (per$1,000 of valuation) BARNSTABLE FD $63293 Town 9.26 TAX . Fire District Rates Land Bank Tax $67.37 Barnstable 2.61 C.O.M.M 1.38 Cotuit 1.69 Hyannis 2.54 Total: $2,945.85 W. Barn. 1.54 http://www.town.bamstable.ma.us/ComeOnhi/Department.../resultsk02.asp?MAPPAR=29807 5/30/02 Town of Barnstable Assessors Division Page 2 of 3 utner mates ' -Total does not include special assessments- Land Bank 3%of Town Tax Due to rounding differences these values are.approximate. Sales History "Top Owner: Sale Date: Book/Page: Sale Price: NOW D, MARY M 9/30/1997 10980/ 108 $ 164,000 GOLDING, CLAIRE E 8/15/1995 9821/335. $ 1 GOLDING, RALPH H &CLAIRE 4/15/1984 4076/090 $96,500 KENNY, ROBERT M 1/15/19811, 3301/49 $45,000. Land and Building Description "Top Land Building. Lot Size (Acres): 0.8 Year Built: 1981 Appraised Value:$72,000 Living Area: 2106. Assessed Value: $72,000 Replacement Cost:.$.178,362 Depreciation: 6. Building Value: $.167,700 Construction Details "Top Style: Cape Cod Interior Walls: Drywall_ Model: Residential Interior Floors: HardwoodCarpet Grade: Custom Grade Heat Fuel: Gas Stories: 1 1/2 Stories Heat Type: Hot Air Exterior Walls Wood ShingleClapboard AC Type:.Central Roof Structure: Gable/Hip. Bedrooms: 4 Bedrooms Roof Cover: Asph/F GIs/Cmp Bathrooms: 2 Bathrooms Total Rooms: 8 Rooms. Outbuildings& Extra Features "Top Code Description Units/SQ FT Appraised Value Assessed Value FPL2 Fireplace 1 $.2,800 $2,800 Building Sketch "Top or x http://www.town.bamstable.ma.us/ComeOnIn/Department.../resultsk02.asp?MAPPAR=29807 5/30/02 r Town of Barnstable Assessors Division Page 3 of 3 Sketch Legend BAS First Floor, Living Area FST Utility Area (Finished.Interior) UAT Attic Area (Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area (Finished) UHS Half.Story.(Unfinished) CAN Canopy FUS Second Story Living Area (Finished) UST Utility Area (Unfinished) FAT Attic Area (Finished) GAR Garage UTQ Three Quarters Story(Uni FCP Carport GRN Greenhouse UUA Unfinished.Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper.2nd.Story(Unfi FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) Back-Forward - Home 1.Departments (Town Information 1.Contact Town Hall Website Developed and Maintained internally by the Town of Barnstable Information Systems Department Town Hall-367 Main Street Hyannis,MA-1 02601 -.508-862-4000. DISCLAIMER: Although we strive to provide accurate.information,we are only human. Please consult directly with the appropriate department if there is a question of accuracy. Copyright 20010 Town of Barnstable. All Rights.Reserved. http://www.town.bamstable.ma.us/ComeOnIn/Department.../resultsk02.asp?MAPPAR=29807 5/30/02 Septic Inspection Information >Y Data Entry Date 1/20/98 Septic Inspect Nod —� Assessors Map 2g8 Parcela .�, 074 Doti 5t3usmess> ;:Number:: 0 Andress: Hanson Lane ,V- aoe Barnstable Inspector Joseph Macomber Inspe`ctdafe 7/8/97 System Status F Com"ment The waste water is over the invert pipe. Permit' ;, Repair Date;: � � Notification Date: F 4/18/98 Eng/Installer:; Installer RepairDeadltrt�e-Date. 6/18/98 °F1HE ray, Town of Barnstable ti Regulatory Services ces BARNSTABLE, 9 MASS. Thomas F. Geiler,Director 039. i o. Public Health Division Thomas McKean,Director 367 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TO: Mary M. Nowd Date: August 16, 2000 9 Hanson Lane Barnstable, Mass. 02630 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 9 Hanson Lane was inspected on,by Robert ' Bortolotti a Massachusetts licensed septic inspector The inspection of your septic system showed that your system failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The wastewater liquid level was above the invert pipe in the leaching pit Our records show that the system has been in a failed state for more than two years and you were notified by certified mail on 4n198 of this septic systems failure. This will be your final notification before the board pursues court action. Therefore, you are again directed to hire a licensed Town of Barnstable septic system installer to sketch a proposed system into compliance with 310 CMR 15.00, The Environmental Code, Title 5 within (14)fourteen days of receipt of this notice. The septic system must be brought into compliance within (30) Thirty days of your receipt of this directive. You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into buildings, onto the surface of the ground, or into surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health �`? �--5 Serer Information <<< Rota Et#ty dl 1/20/98 >< ssst ' f 298 « rE 074 > -71 [uie cars§ Hanson Lane 13111.Wi lBarnsfable Irispfr> Joseph%Macomber '. [1(SfklS F jEnsp ts;dat I 7/8/97 ......:::::::::.:,:,:: C1Ylt7i4Tf# THE WASTE WATER IS OVER THE INVERT PIPE.Passed inspection .::..::.::..:......... on 7/23/9-7 ?< 1Chaf[9n, t#t / / t►31!is44 ll.;:<.: n auer pl!Dgadl pG€ < 6/18/98 U 44 � K} Q-) v Its co ---- UNITED STATES POSTAL SERVICE � P r+j v 'First4 &,Mail ai f� —• 'Postapge&'Fees Paid - USPS f 4� ?e APR C, Permit N8`G-10-•--- I Ff �`�:.'. . © Print your dame, address, and ZIP Code in this box-o PuNI!,0 f Town cflVr�Yvj�Aead 77 P.O.Box5gt� I Hyannis,Massachusetts 02601 I I I a I , Sm Complete ENDER: ems 1 and/or 2 for additional services. I also wish to receive the H ■Complete items 3,4a,and 4b. following services(for an ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ei ■Attt�?this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address ` ■Write'Retum Receipt R uested'on the mail piece below the article number. d p ea P 2. ❑ Restricted Delivery N t ■The Return Receipt will show to whom the article was delivered and the date delivered. Consult postmaster for fee. 0 f v 3.Article Addressed to: 4a.Article Number� E ✓! 4b.Service Type 0 ��'ere d Certified H i'Mail ❑ Insured c sib (ieoeipt for Merchandise ❑ COD fa 7 / Delivery o lZ lZ 3 a 5 Receiveo- :'(r ut-lvdrnc/ ___._Aee's Address(Only if requested W and fee is paid) r 6.Sign e: d e see or Agent) X J N PS Form 381 December 994 _ 102595-97-B-0179 Domestic Return Receipt Z. 003 498 831 rs Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail(See reverse) Sent Street&N r P State,&ZI Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee uO Return Receipt Showing to Whom&Date Delivered Q Return Receipt Slowing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ co) Postmark or Date E �Z- 7 rn o_ Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service y window or hand it to your rural carrier(no extra charge). i 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Z cc return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address M rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the C addressee,endorse RESTRICTED DELIVERY on the front of the article. 00 . M 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti 6. Save this receipt and present it if you make an inquiry, 102595-97-B-0145 } U) e n. Town of Barnstable BAMMB� � Department of Health,Safety, and Environmental Services ' ,m� Public Health Division �E039. P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health April 6, 1998 Claire Goldling 9 Hanson Lane Barnstable,MA 02630 ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE, TITLE 5. ' The septic system owned by you located at 9 Hanson Lane, Barnstable was inspected on July 14, 1997 by Joseph Macomber,a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: 0 The wastewater liquid level was above the invert pipe in the leaching pit You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within thirty(30)days of receipt of this notice. You are also directed to bring the septic system into compliance within sixty(60)days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground,or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean,R.S.,C.H.O. Agent of the Board of Health q\health\db6les\tit1e5 i.doc , �TME Town of Barnstable • � Department of Health, Safety, and Environmental Services AMS& a Public Health Division 039. o 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health TO: l-,2, Gn fjl/\G� DAT . -Aarn-S41-yL Met- ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. I The septic system owned by you located at I`^'�.SaA ,I�rnS � was inspected on`� 1 al-7_ by �1�cn,,bes , a Massachusetts licensed septic inspector. - The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Y r\ a— You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code,Title 5 within v €e een days of receipt of this notice. You are also directed to bring the septic system into compliance within tfiiays of receipt of this order letter. (� D/ You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health ,w�mA&ripu 1Je5i.a« DATE: 7/1 10 PROPERTY ADDRESS: ,Claire Golding pO rI 9 Hanson Lane - R m J'U`L 21 1997 i Barnstable,,Mass,02630 TDWNOfIjARNSTASLE i HEALTH DEPT. A_ e On the above date, I Inspected the septic system at the above a� e V This system consists of the following: 1 . 1-1000 gallon septic tank. 2. 1=1000 gallon leaching pit. Based bn my IntAc�actlon, I certify the following conditions: 1 . this is a title five septic system. ( 780ode ) 2. The septic system is in failure. .The waste water is over the the invert pipe to the leaching pit: 3. Septic system must be upgraded to atitle five septic system ( 95 Code .) •SIGNATURF, : Name J P Macomber Jr_ i ------ Company:* ompany J . P .Macomber &- Son_Inc , Addres8:_-8eac-bb-----=�-- -- __Centerville . Mass__02-632 ' Phone:---SQ8�7-5-�338------- - 1 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • .}OSEPN P, MAC•OMBER' & SON, INC. 7ankrCaupoolrleschileId6 PumP*d Ik 1nitalltd Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION " ONE WINTER STREET. BOSTON. MA 02108 617.292.5500 WILLIAM F N ELD TRL DY COXE Govcmor Sccrc Lard ARGEO PAUL CELLUCCI DAVID B STRURS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr PART A CERTIFICATION Property Address:9 Hanson Lane Barnstable,Mass Address of Owner: Date of Inspection7/8/97 (If different) Name of Inspector: Joseph P. Macomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Jose Ph P. Macomber & Son . TriC . Mailing Address: Sox b Centerville , Ma . 02632-0066 Telephone Number: -J 38 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reponed below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _-64eeds Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 7 The System Inspect shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: /00 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: I BJ 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not •The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if.the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 20 DEP on the World Wide Web: http:/Avww.magnel state.ma.usr0ep LJ Printed on Recycied Paper la n4pwo- 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Hanson Lane Barnstable,Mass. Owner: Claire Golding Date of Inspection:7/8/97 B) SYSTEM CONDITIONALLY PASSES (continued) Y�!�f sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 1W The system required pumping more than four 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 obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: �0 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Q The system has a septic tank and soil absorption system (SAS) and the SAS i5 within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. d&7 The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the pr'es'en�a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance �, (approximation not valid). 3) �OTHER �1G (revised 04/25/97) Pago 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Hanson Lane Barnstable Ma 02630 Owner: Claire Golding Date of Inspection: 7/8/9 7 D) SYSTEM FAILS: You m indicate ei;-.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CmR 15.303. The bans for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cornea the failure. Yes No Backup of sewage into facility or system component due to an 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 thedistribution d tr bution box above outlet invert due to an overloaded or clogged SAS or cesspool Z _ Liquid depth in eessOeek is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 9 Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate'nitrogen. Q LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No . the system is within 400 feet of a surface drinking water supply 'd 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) The owner or operator of any such system shall bring the system and facility into.full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 Hanson Lane Barnstable Ma 02630 Owner: Claire Golding Date of Inspection: 7/8/9 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and'the system has been receiving normal Flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. — As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. — All system componentsWluding the Soil Absorption System, have been located on the site. — The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if cjfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. — Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) (revised 04/7S/97) Pep• 4 01 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: 9 Hanson Lane Barnstable Ma 02630 Owner: Calire Golding Date of Inspection.?/8/9 7 FLOW CONDITIONS RESIDENTIAL: Design flowbe�� /bedroom for S.A.SNumber of Number of current residents. Garbage grinder (yes or no):•A/ Laundry connected to system (yes or no):-Me Seasonal use (yes or no):_A)_D water meter readings, i(available (last two (2) year usage (gpd):� '7ilu'6—�3/9.6� Sump Pump (yes or no): d / 74`Z ` -J A,004 -VS lG' Last dare of occupanc),.IE 7 COMMERCIAUINDUSTRIAL: '' Type of establishment: NM Design flow: gallons day Grease trap present: (yes or no)1 industrial Waste Holding Tank present: (yes or no)A Non-sanitary waste discharged to the Title 5 system: (yes or no).AL/.r Vvater meter readings, if available: ZA 46 Last date oc occupancy: OTHER: (Descr6e) 1 Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of i' rmat n5 vm ? k t 1 ,J�J X System pumped as part of inspection::: (yes or no) T „` If yes, volume pumped: O allons �r Reason for pumping: !�4i / TYPE STEM TYPE tan k/d4;"butu_Jp-dsoiI absorption system Single cesspool Overflow cesspool _ Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) A/7 It I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (If known) and source of Information: Sewage odors detected when arriving at the site: (yes or no)1_01 (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 9 Hanson Lane Barnstable Ma 02630 Owner: Claire Golding Date of Inspection: 7/8/9 7 SOIL ABSORPTION SYSTEM (SAS):, (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 0 leaching chambers, number: leaching galleries, number: leaching trenches, number,length: 0 leaching fields, number, dimensions: overflow cesspool, number:�V Alternative system: N Name of Technology: Comments: (note condition of soil, sign of hydraulic failu e, le I of ponding condi on of vegetation, etc.) �,Ye , �¢ > CESSPOOLS: (locate on site plan) Number and configuration: A14 Depth-top of liquid to inlet invert: d W Depth of solids layer: if//4 Depth of scum layer: �WIV Dimensions of cesspool: d2el Materials of construction: 111J9 Indication of groundwater: d,/4 inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 5 _S I't" 44 11GSP. PRIVY: (locate on site plan) Materials of construction: /L/ Dimensions: iU/f Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.). (revised 04/25/97) Page 8 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:9 Hanson Lane Barnstable Ma 02630 Owner: Claire Golding ; Date of Inspectiorv7/8/9 7 BUILDING SEWER: (Locate on site plan) f/ Depth below grade: / Material of construction: _cast iron Y 40 PVC _ other (explain) Distance from pr(ivate water supply well or suction line iC-/ Diameter _� Comments: (condition of joints, venting, evidence of lea ge, e ) t SEPTIC TANK:1�'D9/P.G<'D.r�r (locate on site plan) Depth below grade: d" Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list aged Is age confirmed by Certificate of Compliance,f, Q±(Yes/No) Dimensions: Sludge depth:_ Distance from top of Judge to bottom of outlet tee or baffler_ Scum thickness: Distance from top of scum to top of outlet tee or baffle:e_ Distance from bottom of scum to bottom of outlet tee r baffle: 0 How dimensions were determined: Comments: (recommendation for pumping, conditi n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:lf(4(/C (locate on site plan) Depth below grader Material of constructionN�i concretetJiPmetal J.(QFiberglass //pPolyethyleneZ2�bther(explain) Dimensions: .AIA Scum thickness:_/f Distance from top of scum to top of outlet tee or baffle:A/9 Distance from bottom of scum to bottom of outlet tee or baffleA&_ Date of last pumping: Zo Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) VMS /rlD7" 6 T (revised 04/25/97) Pay• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Hanson Lane Barnstable Ma 02630 Owner: Claire Golding Date of Inspection: 7/8/9 7 TIGHT OR HOLDING TANK: ),Z,(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:�� Material of con s(ruction:concrete eAmetalVAl'iberglass�oPolyethylene,e,other(explain) Dimensions: e,,f Capacity: Al,�[ gallons Design flow:_ gallons/day Alarm level: Al � Alarm in working order,C& Yes;,(A No Date of previous pumping: IV19 Comments. (condition of inlet tee, condition of alarm and float switches, etc.) a207 ZM5L--02E DISTRIBUTION BOX- (locate on site plan) 16? Depth of liquid level above outlet inver Comments: (note��{{f level an distribution is equal, evidence of solids carryover, evidence of eakage into or out (box, etc.) PUMP CHAMBER:41iye (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.) `22d (revised 04/25/97) Page 7 of 10 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSIEM INFORMATION (continued) Properly Address; 9 Hanson Lane Barnstable Ma 02630 Owner: Claire Golding Date of inspection: 7/8/9 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) .zz b (rvvia•d 01/25/97) Page 9 of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Hanson Lane Barnstable Ma 02630 Owner: Claire Golding Date of Inspection: 7/8/9 7 Depth to Groundwater l� Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record —K Observation of Site (Abutting property, observation hole, basement sump etc.) _ZDetermine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records :� Check local excavators, installers Use USGS Data Describe in your own words ho", you established the High Groundwater Elevation. (Must be completed) Property on high ground, no signs of water intrusion when we pumped the leaching pit. (revised 04/25/97) Page 10 of 10 (, .•.�.+-n .r+�-.+.-nr r m�s-...�•r.rr-..•.�.•+-.rr:+.rnnnn'��u•+r•ms nm m,.-•.+--v.ra--c r..-rr..--- - .- TOWN OF /r7 �i�, P. WARD OF HEALTH � SUIISURFACF 9FWA(;F DISPOSAL SYSTEM IN81'FCTION FORM - PART D - .CFHTJFICATIc)�r f --.,..-..-n•n..s,,-,.r.t-r,..rrn•�•.�-•,,.rn�..,...r-•r+..rr.ew...r.......-.•.n..-. ...,.n...,,-.-...v-,�-.+T..r _�.-- •-.- -_. 1 -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 9 Hanson Lane Barnstable,Mass. 02630 ASSESSORS MAP , BLOCK AND PARCEL # OWNER' S NAME Claire GOLDING m� PAR7' D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & 'Son , Inc . COMPANY ADDRESS Box 66 Centerville , Ma . 02632-0066 5tr9vt Town or C1ty Stat• I P COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1 578 CU TIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system n - this address and that the inrorination reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and an,r recommendations regarding upgrade , maintenance , and repair are cons isten ! with my training and experience in the proper function and maintenance o � site sewage disposal systems , Check one ; System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public Iea1Ll� or Lhe environment as defined in 310 CMR 15 , 303 . Any faii ( re crit is not evaluated are as stated in the FAILURE CRITERIA sectie!; o .` t s form . System FAILED; \ The inspection which I have c�on ilcted has found that the system fn . ls tC Protect the public health and the environment in accordance with T �, ! P 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection fo m . inspector Signature Date one tification must be provided to the OWNER , the BUYER copy of tjji7cer ( Nhero appIIcable ) and the DOARD OF 11BAL1'll Ir the Inspection FAILED , the owner or operator ahaII upgrado t h a ayote � - ir.hin one year of the date of the inspection , unless allowed or require(: otherwise as provided in 310 CMR 15 . 305 - parts+ . �+c 3 • S,C� << W 7 � ti - SbIV 3��1 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualification as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. lunc 8, 1995 Acung Dircctor of the ton of Watcr Pollution�Contr�ol . `C�' h • { b p � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t% Q PART A RECEIVED CERTIFICATION (continued) 1461 // � ► JUL 30 1997 Property Address: [?61� S o1n �� Owner: c, `' TnWNOFBARNSTABIE Date of Inspection: G" �� �` / 14EALTHDEPT. � ?,/-'3 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Al1,9 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 /4, L h Owner: / a I ( � Date of Inspection: -2/a 3 D) SYSTEM FAILS: /V�-1 / You must indicate ei;,,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: &6 r Date of Inspection: 7 /v? 3 ��/7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates. during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. — The facility or dwelling was inspected for signs of sewage back-up. �. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of J Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. ✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (reviaadr04/15/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q SYSTEM INFORMATION Property Address: / /4 r S 0 4-k L Owner: Date of Inspection: l FLOW CONDITIONS RESIDENTIAL: Design flow:.dR 0 p.d.Pbedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no): /yO Laundry connected to system (yes or no): Seasonal use (yes or no): Md Water meter readings, if available (last two (2) year usage (gpd): Cm A - 3 7�ooc) S/�, f $`�� = .3yw"r, Sump Pump (yes or no): Last date of occupancy: A COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORD and source of information: A k a-y /9 r AK 7 Xy S 7 .� ✓ i �.rho /3�,-., f r��.�,.,�./ �'/KKK. System pumped as part of inspection: (yes or no) N If yes, volume pumped: gallons Reason for pumping: TYPE 9f 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE/of all components, date installed (if known) and source of information s irz, //< CA Sewage odors detected when arriving at the site: (yes or no) /mod (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: , /02 3 /�7 BUILDING SEWER: A//4 I (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) it Depth below grade: Material of construction: /concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:_ ,S fit' X c 1(d, Sludge depth: / ri- i Distance from top of sludge to bottom of outlet tee or baffle:��/ Scum thickness: -A/E Distance from top of scum to top of outlet tee or baffle:No Distance from bottom of scum to bottom of outlet tee or baffle: No S 4- 1`4 How dimensions were determined: /Oro e Comments: (recommendation for pumping, condition of inlet and outlet tees baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc� — e S w� L' A ' ,.� ,,,,�o -4•, "3, c.��cv.. "' /a s GREASE TRAP: �!/)9 (locate on site plan) Depth below grade: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert; structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C L SYSTEM INFORMATION (continued) Property Address: �l /��^�'s v r. L Owner: o I cf :.. Date of Inspection: .� 7 TIGHT OR HOLDING TANK: N/9 (Tank must be pumped prior to, or at time, of inspection) (locate,on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes;_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Gay L. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) ram" a Ar PUMP CHAMBER:, ' 9 (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.) (revised 04/2S/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: q Ye—S o i, La . Owner: F /�42, 4 j^C Date of Inspection: tl 7/y-/ SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation. not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Tye' leaching pits, number: 6 X 4r4c­L, .11 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number.- Alternative system: Name of Technology: Comments: (note co dition of soil, so ns of hydrau is failure, level of ponding, condition of vegetation, etc.) W K .� L c. .,,X. �' h cr4 s r �GGI C� � L .`G.1ws t�JK, .<2-Lo^ CESSPOOLS: 1�9 (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 (cesspool must be pumped as part of insPection) Comments: (note condition of soil, signs of.hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: Al 1-9 (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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Q / / SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks I afCr locate all wells within 100' (Locate where public water supply comes into house) 35 ' 3<6 3s y6 y6 � (reviaad 04/25/97) Page 9 of 10 I � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q SYSTEM INFORMATION (continued) Property Address: / H<, 50 L�' Owner: Go lS r h 5 Date of Inspection: ? /.?3 / c 7 Depth to Groundwater�O'�Feet adjusted high groundwater level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers , Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) J V s G S G r�u r.� N1 a.�"�r /'f1r•.`,p� S�o c„J � Boa e►.t �✓ti.T t.r d 7z- /G-r-1-c� (revised 04/25/97) page 10 of 10 r 4 TROY WILLIAMS dw* SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection TO 19 Hummel Drive (508) 385-1300 South Dennis,MA'02660 COMMONWEALTH OF MASSACHUSETTS t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONME py ONE WINTER STREET, BOSTON, MA 02108 6 A92.5500 PROTECTION WILLIAM F.IWELD Governor ARGEO PAUL CELLUCCI TRUDY CORE Lt.Govemor Secretary SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM DAVID B.STRUHS PART A Commissioner CERTIFICATIONProperty Address: 9 17444-h 5 a L., �h 1,3�t,rh S,�,,,b�t Date of Inspection: 7 /a.3 /q 7 Address of Owner: n Name of Inspector: Troy Williams Of different) -/`''►��- h c, I am a DEP approved system inspector pursuant to Section 15.340 of Title S(310 CMR 15.000) / h S `� L h / Company Name: T r o v W i 1 1 i d m s Mailing Address: Seat i C i n c n e,,t i 011 s �4 Numm.1 /3ur.,5 �a6 Telephone Number; f R n Q� Z 1 ��� 1 S 4 If4 a MA 0 2 6 6 0 CERTIFICATION STATEMENT a•Z G3 I certify that I have personally inspected the sewage disposal system at this address and that the info and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system- information reported below is t true,accurate . Zasses _ Conditionally Passes — Needs Further Evaluation By the Local Approving Authority Fails l Inspector's Signature:. S �_'--�L•�.•.et�tw,.2 Date: ' The System Inspector shall submit a copy of this inspection inspection. If the system is a shared system or has a design(low of 10,000 rt to the prol submit ving Authority within thirty the report to the a gpd or greater,the ins d t days a completing this appropriate regional office of the Department of Environmental Protection. The originalashould bhe e sermitto tthe systeem owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: �I have not found any information which indicates that the system viol Any failure criteria not evaluated are indicated below. ales any of the failure criteria as defined in 310 CMR 1 S.303. COMMENTS: 81 SYSTEM CONDITIONALLY PASSES: /v One or more system components as described in the'Conditional Pass"section need to be replatxd or completion of the replacement or repair,as approved by the Board of Health,will pass. repaired. The system,upon Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined• Compliance (attached) indicatingoperator has provided the system ins ,explain why not. that the tank was insWled within inspector wide a copy of a Certificate of the septic tank,whether or not metal, is cracked, structurallyu twenty(20)Years prior to the date of the ins pection;or failure is imminent. The system will ^sound,shows substantial infiltration or exfiltration,a tank pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/2S/97) Page t of t0 DEP on the vibdd Wide vu.h- hen•a.... _--- - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: / Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or pipe(s) or due to a broken, settled or uneven distribution box. The system will ass inspection if(with a obstructed Board of Health). Describe observations: y P pe broken i approval of the pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed Pipe(s), The system will ass inspection if(with approval of the Board of Health): broken pipes) are replaced p obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/� Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to public health, safety and the environment. g protect the 1) SYSTEM WILL PASS UNLESS BOA WHICH WILL PROTECT THE P RD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER UBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: RMtNES THAT _, The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surfs tributary to a surface water supply. ce water supply or The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds supply well. the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate less than 5 ppm. Method used to determine distancePounds indicates that (approximation not valid). nitrogen is equal to or 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A g I , CERTIFICATION (continued) Property Address: / /Au» S o,�% Lh , Owner: Date of Inspection: D) SYSTEM FAILS: You must indicate ei;,,er "Yes" or "No" as to each of the following. I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAILS: N11119 You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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-fWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility requirements of 314 CMR 5.00 and 6.00. Please consult the local regional ffice f of the Departments orull compliance wihhfurther inforrt omati treatment program (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: He, Sv •� LH Owner: r lCl Date of Inspection: coon:' p 7 /a3 /y�� Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receivin flow rates, during that period. Large volumes of water have not been introduced g normal as part of this inspection. ced into the system recently or _ As built plans have been obtained and h examined. Note if they are not available / e with N/A. The facility or dwelling was inspected fo r or signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site . The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition f baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. o The size and location of the Soil Absorption System on the site has been determined based on: The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. V _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [15.302(3)(b)] (revised,04/25/97) Pa90 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q L SYSTEM INFORMATION Property Address: 0 11 L H Owner: Date of Inspection: � -2 3 /5-2 RESIDENTIAL: FLOW CONDITIONS Design flow:�o 9.P-d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no): No Laundry connected to system (yes or no): Seasonal use (yes or no): 1%16 Water meter readings, if available (last two (2) year usage (gpd): oov Sump Pump (yes or no): IVO !� /l:+c�s 9s G = Last date of occupancy: COMMERCIAUINDUSTRIAL: A149 Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes orno)_ Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if.available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION nPUMPING RECORD and source of information: J System pumped as part of inspection: (yesOor no) /v4L> h "rH If yes, volume pumped: �—gallons Reason for pumping: TYPE 9f 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information-:-' s - .6 ;.��. Sewage odors detected when arriving at the site: (yes or no) /mod (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION (continued) Property Address: I 144-^ So"AL t., . Owner: Date of Inspection: / � /a3 -7 BUILDING SEWER: N/9 (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade:��r / Material of construction: t✓concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:_ �$' r JrCr ' ECG l o pv Sludge depth: / Distance from top of sludge to bottom of outlet tee or baffle:,2—�`r Scum thickness:- -"E Distance from top of scum,to top of outlet tee or baffle:No S L v K, Distance from bottom of scum to bottom of outlet tee or baffle: No ,S e—%J How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees baffles, depth of liquid level in relation to outlet invert, structural integrity, evi ence of leakage, etch—� S ,�111.! ` �� a�G h a_ o / rJ u►�/z S / / as,Ar i,J cc GREASE TRAP: Af/J9 (locate on site plan) Depth below grade: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert; structural integrity, evidence of leakage, etc.) (revised 04/25/97) Pa • 6 Q of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �1 SYSTEM INFORMATION (continued) Property Address: �' /T� a r. f',,. , Owner: Ci o I cl :.. Date of Inspection: TIGHT OR HOLDING TANK: A 4(Tank must be pumped prior to, or at time, of inspection) (locate,on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order Yes; No Date of previous pumping: _ Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Gv<- Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into o C- �. r out of box, etc.) 1,4 J�`l ev f 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.) (revised 04/25/97) Pegs 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: G.1 Owner: Date of Inspection: 7 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation, not required, but may be approximated by non-intrusive methods) , If not determined to be present, explain: Type: _ leaching pits, number:ei+c leaching chambers, number:_ leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note co dition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation, etc.) WK- G.,.J t v CESSPOOLS: (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(cesspool must be pumped as part of insPection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ` PRIVY:_Al/ (locate on,site plan) Materials of construction: F Depth of solids: Dimensions: Comm ents: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) --------------- (revised'04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I II SYSTEM INFORMATION (continued) Property Address: gca.h •Sd'� 4ti . Owner: Date of Inspection: 7 /� 3 �97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (�.�a ft✓ L'`^ '- 35 66 W6 � 46 . r (revised 04/25/91) page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 L� Owner: GO Id I A. Date of Inspection: 7 /a23 � �7 Depth to Groundwater#20'LFeet adjusted high groundwater lewd . Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) J 764 c►)- e-cA —o /GJ e- I . (revised 04/25/97) Page t0 of t0 t lt- j THE COMMONWEALTH OF MASSACHLdSETTS BOARD OF HEALTH �U-liifnl................OF.....! n/ .......................................- Appliration for Biipnsal Works Toauuurtintt Vantit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal ystem at: - Y. Elf--��►/: � ocatW. ddress or Lot No. ............. .. Owner ....................................................... Adr1��'1v- aW .__. ... .._.. _L Installer Address 30 6 9 Q Type of Building Size Lot.2� .............. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder Other—Type T e of Building _______________ No. of ersons______________.__._.___.__._ Showers G� YP g ------------- P ( ) — Cafeteria ( ) Q' Other fixtures ............................ . W Design Flow_.___.____.5.?r_________________________gallons per person_per day. Total daily flow------- -_37__Q______ .............gallons. ii > _ / ii W4 Septic Tank—Liquid capacit/!QX_gallons Length.______.6. _ Width.410.._ Diameter_�__��_._. Depth_.-�_B_.-- Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------I............ Diameter--------6....... Depth below inlet.....,........... Total leaching areas.3._fr_0_...sq. ft. Z Other Distribution box Dosing ank Percolation Test Results Performed b ` /NG. Date__. _ /_ -�Sf Y �-_/Z.•---- 14 Test Pit No. 1.... .._..minutes per inch Depth of Test Pit----- Depth to ground water...Ar ___-- 44 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water_- L!7__X_ > ------ ------------------•- • __---------•------------_____ _------------ ----------------------------- •--••••---------------- O Description of Soil........... -__ /"z_' I_..� sL�S�I� x ........................................... ' +` � � 1'!�I.r /-tdh� n ...- :' s�T�h/,e ��--------_--- V 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 TT T;- p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i e by the beard of/ieth. Si e --1�� 7` /a,/qy, � Date Application Approved By... ,� -- ___-• --- --- -- =.................. ..... - Date Application Disapproved for the following reasons-----------------------------•------------------------------------------ ........................................ .................•--•---•--••-•-•••••-•--•---•--------•••••••-------•---•...----------.......-------.-..--••-•-•-------•---------••-------•••-----•-------------•-•---••-•-----•-•-••-- Date PermitNo..........................-............................... Issued--- .......................... Date r No........................,�' . Fms.............................. THE "COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH f. fstl`e ......I......._.OF.....> 3.it/ j ". ..... Appliratiou for Dhip ial larks TouB�rnrtion ranfit Application is hereby made for a Permit to Construct O or Repair ( } .an Individual Sewage Disposal System at: .. 1.- �.v ....w. ....r.�..c tt --------------------------------•-•----••- a ,' 1_. Locat ddress or Lot No. �.. jjOwner A�ll�a�r��, Installer Address Type of Building =4' Size Lot.;�5o _9' _.....Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ,kV6 aOther—,Type of Building ............................ No. of persons............................ Showers ( ) = Cafeteria ( ) il d / Other fixtures ------------------------- ----------------------------•-•---••---------------------------------------•----•••-•-•-•••-••-••---••-•-•----••-••-•-•--•- W Design Flow............55_-_-- _--•-----_•-_gallons per person per day. Total daily`flow_......... 3P....................gallon. WSeptic,Tank—Liquid"capaclt}/0,0Q.gallons Length&...6_.._. Width.44-2W_.. Diameter.-- Depth,,,T.-118.... x Disposal Trench—No. .................... Width.................... Total Length................_--- Total leaching area....................sq. ft. Seepage Pit No.......Fs............ Diameter--------6`..... Depth below inlet-...,5........... Total leaching area- . -...sq. ft. Z O'ther Distribution box (I✓) Dosing tank ( ) a Percolation Test Results Performed by._Zy..e�2,.. `1?% .1! ................ Date �1_................................ Test Pit No. 1.._.5._...minutes per inch Depth of Test Pit...... Depth to ground water__r� r !r P P P $�' f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground -----•-•-•-•----�--/----------•-•--• --•----••-•-......--•••- ......•-----.........--•-•-----•--•-........................................................ D Description of Soil........... ��'E :L -•- .. l?+,:3 1 /C... --------------------------•-•-•..----- rJ W --------------------------------------------------------------------------------------•-•-----------------•-------------....---------•----------------------------------------•------------------------ 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 T 1 TLE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i e by the board off h th .... atoH licaton Approved B �% �. PP PP Y-• •f'----� -- - - ,114- ..... ........ A ;F = Date Application Disapproved for the following reasons----------------------------------------------------------- ..................................................... ..............e_...................................._.........................................._........................................_.........._,--------------------................................. R Date Permit No............... Issued ........................ Date, t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Y . • . o�...... �:. r.. ........................... Tntifiratr of TompfiFanre THI 9 T FY, That the Individual Sewage Disposal System constructed �r Repaired ( ) by /--------------------•--------------------------.. .....�..... ;a• /ns at..= ' has been installed in accordance with provisions of TI'�-:,.—)' of The State Sanitary Code as described in the" application for Disposal Works Construction Permit ........... ................. THE ISSUANCE OF THIS CERTIFICATE SHA 6NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION' SATISFACTORY. DATE................................................................................... Inspector....._.. .., THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ! a - .... ...�.... ..............OF.---.. . .......................... No......S.:'.......... Disposal � str ion rranit µ: s Permission is reby granted-----�. . .. ......... .•��---.-------------------•----••--•----.................................................. to at Nonstr o�r�]� r (' n Individual=Se���ge�Di al Sys gm#� �fQD �.... rg ' : /qT�• Street q7%-- ----- --- n'�%Y as shown on the application for Disposal . ;OikS ConstructionePemr No. ` ated.......... ........................ ...... .1 . _._.. ---_ Board of Health /� .r DATE----=�-`-----••-----•-•--�----•-- � FORM 1255-''HOBBS & WARREN, INC.. PUBLISHERS t r f f C x ;�' I�/T w�� ' 5:rv../�. �SD�����Z' �/bE� • A66 -..�/r,L " r.. eta"'''r 6 �4�°/ '', . `'' 1 ' • � •f ' 4. 17 / � � Lt/•��� ,�i is T,i•��'. / �/ 1 . E 42 1 vacs � .1- 1 43 ON - -rO;p&0t,7"0r-,q/hfL4.A.)T S LJ I. rs Df©' TOW/�/;REGOS / 4 / I%b 7-0 tom/" WAT'E e 45 A VA / L A 3-L E V/ I A/S pert � Al A// /'9U �3�C�C, / ,GO w/nTN �l�� ZS �ccA X>-R/ Vle I-✓A�+ N.d � TO � E TE D PROPOSED 8L• DE'oC9/`�J$ OVE ,e SE ivL* ) 49QE .SY,S7"E/"7 UA144-SS DESI /J FLok✓ '� GaAL/Df3,y �,/- 2c7, DES /GN �..o/9zD//vG 15 USED . PROP054D L- le,geH /q 4EA 300 ::S P� / SYSr M Ccon/5-r1euCT� o�/ SHALL PE;ec0,L T'/O/V TE - 7- ;e.t4 - -ro /"I -9- S'S ENV1R 0A1M E1Q'Tf9L- r '._. 7 f?r . ? T(/L. "o4/N 01 cJL. 4947''�o/v. SIGH ,L f TQ t > Tt t � lee ` 2�o /H/A/. F/A//SI�/�ED T P / /' R O I 0;0 0 ,'7"OP OF `Q UNDAT/!JN A/ O S C iQ 109RE'i9 NfAttHOL.E,0 Co✓E,e To EX'TE/,/D TO TCO P*EVE/VT F/,/ES NIL ,, ` W1-r I/N /' OF F/A//SHE,D G eAT>E FiECJ/"I /NF/LTiP.f'tT//�/C.t. M/N/MU/`? ( /O'N7/ti11M11M---- STONE 2" oA " To�. .�_ _,a►. . 24•.C'OVERS r D/ST 6 / --� `co vE, l,1f15 HE D STOa/ J Box /5- Z` `1 r. l✓/�E ALL '.9go U.Ajp Le D/A. W � t/EL P/TeW Ffi aN L/Al E 11AI- P/TC -gin � S/ �� ��h Dn9 Foo7 . 1¢" F4or ,HIM ocr 14. WASA!EIa ,. 4. 0 GALL A L ON ✓N V,�,e r /A/V E/ P/ T rev . 1wVAF L 7 AC 17-y A,eovNp 7S � �4r�A7"Ez'r'/G NT;� /A/✓�,e-r ' � _ � . �O'tS�..- /2•'a/�//�./: ff + 2 PLO 7— P/. ,Q /v vTTa•,� �L���, / G'e'0 u/v D klATe•� As-'Lev' V R E F,E,e E^J0 E : 5E/NVia' L O 7 �.� fR S $�4�✓N coA/ A pj,. A/v ;e c�TSa5'NlAoTvQN!CA o�/2 DTB/h1'`/H9'L•f N E`.�U HOT8�NHAJ��J;P/LrT/4T_,�H.,�.2f/D TTl�./'S nM/�oP f�TLS.�SA=S Er./,�ET/` /5F a/CT�✓',C r V�-'-GO I</'"-�'fEJ"/Q Ff-'/JcOu,/�'�''�-E1A 1 L_ A s/O fE ovAITY �x 6677, MI/Dy—N�UU7 UTEMM— ! G AF F�NT/—�r jD/?U—T F�FL RERAID / ? RP"MO�G N — —OSAlM 1P, D. _/�AF -1 sr-OP SEP7 / C T/9 NL _ 483 T/ C /J An/ U LEC e Or e oci � Co. 'Pq P/-rS Ta ;5E A /"/-�/ — N � g:re-r . 7"Ni9 T D SE PT/0 TA `/K tN O /4tiD 2O' F ,e OM FO 0A1 DAT/0- A/ THE Q R a U�J S H oc /./ EleEo,jIORGET LOW,JR.� ; -- — -- AI E NT S OF Thl E T �/�/ v v �� ate° — e14 'IM 0 DATE 8 O/�9 ,e D O ie A4 E A L 7TN -- a SU T G . 4- N .S V E y 0 f��'P.e cV'E y I • SYSTEM PROFILE TEST HALE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) To LOW AND WELLER MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM ENGINEER: 42.0 WITNESS: \ BARNSTABLE BOH 2" DOUBLE WASHED PEASTONE �' ti 1.31 RUN PIPE LEVEL DATE: 1/9/78 'i hoc+� EXISTING 1000 FOR FIRST 2' \ 3' MAX. 5 MIN/INCH ° PERC. RATE _ BASE. SLAB GALLON SEPTIC 9 9+t* 39.5' I 42.7' TTANK ( U, H- 10 )177 GAS CLASS SOILS P# �w BAFFLE 39.0' o000 �3$_$ o C] 0 Cl 0 C7 O C7 C7 3 0 38.73 0 C� 4' AROUND n 0 7 C.] CN 6" CRUSHED STONE OR MECHANICAL $o n COMPACTION. (15.221 (2]) 000 $ 2 0 a a Cl C7 0 36.73' Q ELEV. e�°`'G� NPNS DEPTH OF FLOW = 40 0 42 TEE SIZES: *CONFIRM INVERT PRIOR TO 3/4,+ TO 1 1/2�, DOUBLE WASHED '.,;TONE - a INLET DEPTH = 10 INSTALLING ANY PORTION OF SYSTEM LOAM & Locus OUTLET DEPTH 14 2.5' SUBSOIL 39.5' LOCATION MAP NTS FOUNDATION- EXIST. SEPTIC TANK 34' D' BOX 12' LEACHING FAC LITY 6.73' ASSESSORS MAP 298 PARCEL 74 MEY. & FINE 30 0' SAND WITH SIN LANE - STONEs HAN , 9.5 49.0 �h 4"36 50. 0.2 4911 49.2 v p 50.3 50 49.8 4 .2 48.61 I 48.3 L= .12' 49 48.2 1 12' 30.0' '� <P 49.3\ R=30. 4e,3 _48,5 NO WATER ENCOUNTERED e 48.3 I NOTES + 0.0 w 48.4 tiYo 4 .2 GRAVEL I SEPTIC DESIGN: 1 . DATUM IS ALT. BENCH MARK TOP CENTER ` Q 3 46.9 (GARBAGE DISPOSER IS NOT ALLOWED ASSUMED 47 _T EXIST. DWELL DRIVE I ) OF HYDRANT. ELEVATION 50.0 I 1ST FLOOR DESIGN FLOW: .:3;._ BEDRQ,9MS ( 1 10 GPD 3?O�Gpn I I IrI rI WATER c EXISTING E'ER HANG ) 2. MI N....._. ..A.ER 1S _-.--- 7 ,,NSF A 330 GPD DESIGN FLOW c.rs c' - -� _3. MINIMUM PIPE PITCH TO BE 1 /8 PER. FOOT: 6.3 + 43 : 42.5 J SEPTIC TANK: 330 10 42.1 q + a2.5 GPD ( 2 ) = 660 4. DESIGN. LOADING FOR ALL PRECAST UNITS TO BE AA_�riU H-�_�,� 5. PIPE JOINTS TO BE MADE WATERTIGHT. 11ST FLOOR I 41.3 42.2 USE A 1000 GALLON SEPTIC TANK (RE-USE EXISTING) n °� 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. i DECK _ a1.6 , LEACHING: ENVIRONMENTAL CODE TITLE V. I1~� SIDES: --- 2(25 + 12.83) 2 (.74) = 112 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT' I •7 00 TO BE USED FOR ANY OTHER PURPOSE. i + 1+ a .sD BOTTOM: 25 x 12.83(.74) = 237 � " 8, PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. + 4.2 . 417 TOTAL: 472 S.F. 349 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT I + a 1 USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. I J EQUAL) WITH 4' STONE ALL AROUND 10. PUMP & REMOVE R FI BENCH MARK - CTR. OF � (0 LL W/CLEAN SAND') FAILED LEACH PIT CATCH BASIN EL. = 43.7 I I �s + 42.6 4 + 41.0 APPROX. TH LOCATION w LEGEND TITLE 5 SITE PLAN AN 3. a a7. sr? + .9 100.0 PROPOSED SPOT ELEVATION OF a2.o 9 HANSC.)N LANE .� 100x0 EXISTING SPOT ELEVATION IN THE., TOWN OF: 43.9 100 + 42.7 PROPOSED CONTOUR BARN STABLE 44. UCON + 4 .6 ,t (VILLAGE)100 EXISTING CONTOUR PREPARED FOR: HICKEY CONSTR TI ,� v LOT 69 -I- .3 3 68t SQ. F + 41 30 0 30 60 90 BOARD OF HEALTH MA SCALE: 1 " 30' DATE: DECEMBER 10, 2002 6 139.37' APPROVED DATE S 43.9 off W8-362-4541 fox 508 362-9880 OF �lN OF �, �` li P Mqr' �y\�' glJq`> down Cope engineering, Inc, ARNE <y" ��' ARNEH. H. OJALA CIVIL ENGINEERS OJALAQ CIVIL No.2634 t LAND SURVEYORS �� 9�cis - 939 vain t 1 IAN _ az 397 s yarr�outh, rla 02675 ARN H. OJALA, P.',"," .L.S. ,GATE