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HomeMy WebLinkAbout0016 ICE HOUSE LANE - Health 16 .Ice Hduse .Lane Barnstable P A = 258 038003 P Commonwealth of Massachusetts a 5 U 3g— 003 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U/ 16 Ice house In `-` Property Address ' MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable t/ Ma 02669 10/22/18 _ page. City/Town State Zip Code Date of Inspection " Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information %- 13 13 filling out forms on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane rab Company Address Cotuit Ma 02635 City/Town State Zip Code reran 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. Needs Further Evaluation b the Local Approving Authorit ❑ Y pP 9 Y 4. ❑ Fails 10/23/18 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. I Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts 6 Title 5 official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. p 1) 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 contains a 1500 Gallon septic tank as well as a concrete distribution box and 3 500 gallon chmbers in stone 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): � I i S t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Citylfown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form -- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y rY 16 Ice house In u� Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: i 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow 0 ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000,gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No +; 4 ❑ ❑ 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 supplyrLl ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well $ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts Title 5 official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to an question in Section C.5 the system is considered a significant Y Y any Y 9 threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Ice house In u Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 189 Gpd 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No i Last date of occupancy: Date ` . y t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form M11e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped in 2017 Was system pumped as part of the inspection? ❑ Yes ® No I If yes, volume pumped: gallons i How was quantity pumped determined? Reason for pumping: i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 6 M Commonwealth of Massachusetts - Title 5 official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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): Approximate age of all components, date installed (if known) and source of information: 3/22/95 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC '❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Systen is vented through the roof. Tee's are in place t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet Invert, evidence of leakage, etc.): Tank is sound. Levels are normal. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Fie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 9 Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i Ih Dimensions: Capacity: gallons t Design Flow: gallons per day l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - K Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 16 Ice house In Property Address I MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal 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.): Some carry over observed i r i 'i �; t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form (, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4' 16 Ice house In Property Address MCKIMMEY, MICHAEL - Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ? ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System-Page 13 of 18 1 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding no break out 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): s t r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 of 18 I 1 f Commonwealth of Massachusetts e Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N - a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �^ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is requ red for every Barnstable Ma 02669 10/22/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 I ? . t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 TOWN OF BARNSTABLE .. L CAnON 16 Zce Howie Road SEWAGE # i/II.I.AGE [3azn3.ta9.ee, Pla-3-6. ASSESSOR'S MAP & LOP oze h %. Macomge2 2. III , � a � a . � �'���� (AME&PHONE N0. SEPTIC TANK CAPACITY 1500 f[3 o x LEACHINGFACILr Y: (type). 3-500 gae on eeach-i c am p- 3. (size) NO.OF BEDROOMS BUILDER OR OWNER Stephen & Su,3an Schzade2 Znzpec.tion PERMIT DATE: COMPLIANCE DATE: 6/14 0 3 Separation Distance stance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fed of lea c 'n aci ' ) Feet Furnished b o -.r '\ fl v 0 10/23/2018 Assessing As-Built Cards 1 LOCATION 16 Ice Kou.be Road . SEWAGE^q VTLLAGE Bannetatee,/laze. ASSESSOR'S MAP&-�L0 b3� 0�3 IXM. ;r4�DYAME&PHONENO�oeeph R.Macom&ea a2. SEPTIC TANK CAPACITY 150 0 f B o x LEACHING FACILITY:(type) 3-500- gQieoa teaching c am e2e. NO.OF BEDROOMS BUILDER OR OWNER Stephen 8 Susan Scha.ade-, Inspection PERMIT DATE: COMPLIANCE DATE: 6114103 Separdtion Distance Between the. Maximum Adjusted Groundwater Table to thdBottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200.feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 f of feat in ac'' Feet Furnished b • O 0 0 N I 0 I i e http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=258038003&seq=1 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Ice house In Property Address MCKIMMEY, MICHAEL Owner Owner's Name - information is required for every Barnstable Ma 02669 10/22/18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10 +ft feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 3/1/98 If checked, date of design plan reviewed: j Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan N Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 j Commonwealth of Massachusetts p Title 5 official Inspection Form 1a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Ice house In �V Property Address MCKIMMEY, MICHAEL Owner Owner's Name information is required for every Barnstable Ma 02669 10/22/18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included h� } j. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 DATE : 6114103 PROPERTY ADDRESS16 Ice-Kouze Road _ Ba2n.6taC e,1 ffazz _-----_ 4` vv L 02630 On the above date, I Inspected the septic system at the above address. This system consists of the followln g 1. 1- 1500 9 ai-Pon .se tic tank RECEIVE® /� 2. 1-Dizt2.igut.ion Sox, 3. 3-500 ga--'-Pon ieach.ing cham9ezz. JUN 2 0 2003 Based on my inspection, I certify the following conditions: TOWN OF BARNSTABLE 4. 7h.i4 .iz a tit-Pe live ze/2t is zybtem. HEALTH DEPT. 5. The .se/2t.ic .6yztem .ih in /22o/2e2 woak.ing oadea at the /2aezent time. 6. I)uml?ed 3e/2t.ic tank at time o f .inz/2ect.ion. 7. Did not excavate the 500 ga-Uon cham9eaz. 4-5 ' ge2ow g ade. No evidence o/ &ack u12 .in the d.izta.igutjon ox. No .evidence o/ zolidz caa2y ove2SIGNATUR Name : - J__ P__Macomber-Jr . -- , Company :, QatRh P.,_M.�SgLnttc 8_ Son,° Inc . Addr2SS __@Qx _Lt------- z5 ------ MAP :o� ©3 -_Q-eJU Q L Y L LL£,_:J a _226 3 2-0'0 6 6 PARCEL Pnone : 508. 775_ 3338 _ LOT THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds ` Pumped & Installed Town Sewer Connectlons P.0 Box 66 Centerville. MA 02632.0066 775.3338 775.6412 �-\ COMMONWEALTH OF MASSACHUSETTS 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 F CERTIFICATION a Property Address: Ice Xou.6e Ra6c1 Owner's Name: ; 1?npvnf_ � Susan Sch,,za a Owner's Address:Srzmv Date of Inspection: 6114103 Name of Inspector: (please print),7ozel2h P. ('lacomge2 ;/I k Company Name: g. P. N omp Sorg Inc. Mailing Address: ;3 n r AA rnn} 02632 Telephone Number:5 n R_7 7 5_ 3 3 3 R CERTIFICATION STATEMENT : I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: . _ i JeOasses Conditionally Passes ' Needs Further Evaluation by the Local Approving Authority Fails " Inspector's Signature, f Date: �J� The system inspector shal ubmit 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. Notes and Comments a ****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, r Title 5 Inspection Form 6/15/2000 _ page 1 7 Page 2 of 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ! CERTIFICATION (continued) Property Address:16 Ice Kouze Road i3altnz agie, Razz. Owner: . Ro geat Suzan c as ea Date of Inspection: 6114103I Inspection Summary: Check A,B,C,D or E/ _ALWAY complete all of Section D 1 A. S stem Passes: i t fi 0� 1 have not found any y information which indicates that any of the fall ure-crit�er))'a described in 310 CMR / 15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated &re.indicatet�below. Comments: � 11 11 Zh o Ao nt:a Au Lem -gib in PAoRea wo zking crade4,at t'hr B. System Conditionally Passes: ,A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements, If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structural) 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 sepric 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. 9 ND.explain: , l 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 i obstruction is removed r distribution box is leveled or replaced l ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: 16 Ice 11ouze Road Owner: /�Of-e2 (t ' Su.sah Sch zade2 Date of Inspection: 6114103 C. Further Evaluation is Required by the Board of Health:' �Q 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 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. h0 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 1 0 feet but 5 feet or more from a private water supply well•'. Method used to determine distance � "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: f • f 3 r Page 4 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address: 16 Ice floa.se /load Owner: Eogelli Date of Inspection: 6174103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all,inspections: Yes No ackup 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§ox above outlet invert due to an overloaded or clogged SAS or cesspool 15-4-20s 14 - _ d Liquid depth in ee&&p"l is less than 6"below invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number Hof times pumped _ r_/rrty 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. /arty 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) (Yes/No)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. 4 . You must indicate either"yes"or"no to each of the following: - (The following criteria apply to large systems in addition to the,criteria above) yes now ✓ the system is within 400 feet of 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(Lnterim Wellhead Protection Area—IWPA)or a mapped Zone 11 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - CHECKLIST 16 Zee Howse i?aod - Property Address. t` aILn.6 t a e, 77 a s.6. Owner:/2- t x1c. uzan c za e2 Date of Inspection: 6 7 T773 - Check if the following have been done.You must indicate'�Zs"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 v — 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 pan of this insP ection ? Were as built plans of the system obtained and„examined?(if they were not available note as WA) Was the facility or dwelling inspected for signs of sewage backup? r Was the site inspected for signs of break out?. Y _ Were all system components,-a�luding the SAS, located on site ? 41 _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of[he 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 ofthe 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. v _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)j ' 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 16 Ice Xouze /toad i annzs a e, a,3,3, Owner: /�oge?.i. 9 .StL�rLn .Srhnrir/o2 F Date of Inspection: A/1 z /(Z2 . FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):—4-1- Number of bedrooms(actual): DESIGN flow based on 310 CMP 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: . Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system_(yes or no):.G (if yes separate inspection required) Laundry system inspected(yes or no): S Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)):2002- 13 0, 000 gai-eon.a-3 5 6. 17 91')D Sump pump(yes or no): i5b 7UM765, 000 ga-eion.6-4 52. 06 9PD Last date of occupancy: Sl?2ink-Pe2 zyztem ins sae'3ent. COMM ERCIALIINDUSTRIAL Type of establishment: , Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/s ft,etc.): t Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title S system(yes or no):A4 Water meter readings, if available: Last date of occupancy/use:"_ { OTHER(describe): IZOV GENERAL INFORMATION Pumping Records 11/6/01 Tank on2 Source of information: y Was system pumped as pan of the inspection(yes or no): If yes, volume pumped: IwDAallons-- How was quan try pumped determined? Reason for pumping: Heavy Scum R -6otidz .Paue2.3 we2e12ite,6en.t. TYPX OF SYSTEM i 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: Bu.t:2t 1997 Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued), Property Address: 16 Ice Kouze Road- aZnz a 2e, Owner: p�e2t_ S Suzan Sch2adea Date of Inspection: 6/14 LQ 3 , BUILDING SEWER(locate on site plan) . Depth below grade: 0 � Materials of construction:a cast iron !/40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): lint Qqr-PThe 3y,6tem .i's vented th.zough Zhe house vent. ' SEPTIC TANK:Zlocate on site plan)/tr46 Depth below grade: /y � Material of construction: ✓concrete,&Pmetalk)) ftberglassofepolyethylene /UOother(explain) AIF— ' If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or noLf_O(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sll�dge to bottom of outlet tee or battle: 4 }, 7 Scum thickness: (J 4. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: O r How were dimensions determined: Pum12ed at time o� in�s/�ect ion. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of.leakage,etc.): Lumn fhe .tvpfie- }malt 2- 3 yvnn.5 TaP,91 R. au.t ./vnA -nav in Qiacie. -Peakage. lumped tank at time o; inzpect.ion. . { GREASE TRAH[ &(locate on site plan) Depth below grade: T Material of construction;e/ concretolAmetaK/�fiberglasg4�polyethyleno?1/�other (explain): yi9 Dimensions: lie Scum thickness: 111,4 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 410 Date of last pumping: �/y¢ Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): b tea,3e 2aR i.3 not /22e.6ent. 7 Page 8 of I • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM PART C- k SYSTEM.INFORMATION(continued) Property Address: 16 Ice 'Houze /2o¢cl Owner: 'RoktiL ° Su,�ari ,Sch2¢clee rb Date of Inspection: 6114103 TIGHT or HOLDING TAN}Q�G(tank must be pumped at time of inspection)(locate on stte plan)' Depth below grade: AIA Material of construction:Ild concrete,1414 metal,444 fiberglass,d�olyethylene-iW' other(explain): Dimensions: ; Capacity: A1.4 gallons Design Flow: allons/day Alarm present(yes or no): ^+ _ Alarm level: A.1.4 Alarm in working order(yes or no):// Date of last pumping: Comments(condition of alarm and float switches,etc.): 71._ctb_f nn hnfrliaa fnnkA nno `nnf nno tonf DISTRIBUTION BOX: Zof resent must be o erred locate P p )( on site plan), •„ �. Depth of liquid level above outlet invert:Wd `' Comments(note if box is level and distribution to outlets a ual an 'evidenceRof solids ca E q Y tryover, any evidence of leakage into or out of box, etc.): nce o� -3o.2�.c�i rnnn�i n>>on No ot)ir/onro n.4 Yorika4 info 6,7' oti#- o v fip s b4 x PUMP CHAMBERt&/C( 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:) `" a � v P//m!J rhnmOon JA ne) Inn o Xenf „ f Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 Ice Howie /toad 1 Owner: /2o e/zt 'Suzan e 2a eic Date of Inspection: 6114103 SOIL ABSORPTION SYSTEM (SAS): !/ (locate on site plan,excavation not required) 3-500 ua2.Pon Rzeca,6t 2eaehina chamgea.3 -In 6ez-ie-6 If SAS not located explain why: /nnnfor/ • Coo nr,4o 9n Type A14 leaching pits, number: D leaching chambers,number: ���f leaching galleries,number: leaching trenches,number, length: 0 leaching fields,number,dimensions: . overflow cesspool, number: P — � t innovative/altemative system Type/name of technology: �'�1+, �—/ye., Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): l onmy Annd In rPaU Pn.sn Arinrl In tinv medium ,snarl /girl Q,oi orrrjurnfo 4-51 6¢14010 94orlo Aln A;gnA nC PrjCk ll.,Q r1i the d.ietrtigat ion Sox. SO.i.e.6 ate day. Vegetation .i.6 no2ma.9. CESSPOOLSi"cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 0 Depth-top of liquid to inlet invert: /j Depth of solids layer: Al Depth of scum laver. ' Dimensions of cesspool: a "' Materials of construction: Iy Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY(locate on site plan) Materials of construction: y� Dimensions: AM — Depth of solids: 40 Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Pah)/� iA nnf n40Aont ' t i t 1 r 9 i Page 10 of I I ` OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 Ice Hou,3e,, Road Owner: /?6 'eict' S ��i" Sh ch2arLe2 Date of Iospectioo: 6114107 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system Including tics to at least two permanent.reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where publie.tiwater supply enters the building. ' I • O � Q i. L• • S • k 10 • i Page I I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 Ice llou•6e /toad Owner: /2o ge2t )uzan �'ch/zade2 Date of Inspection: 6114103 , SITE EXAM Slope Surface water - Check cellar j Shallow wells Estimated depth to groundwater 30' feet Please indicate (check)all methods used to determine the high ground water elevation: yes Obtained from system design plans on record-If checked,date of design plan reviewed: 6114103 y Observed site(abutting property/observation hole within 150 feet of SAS) ;yam_Checked with local Board of Heal,h-explain: A-6 gu.i-t ea¢d qES Checked with local excavators, installers-(attach documentation) y6 Accessed USGSdatabase-explain:4t :/ltown. 9azn,3ta9.ie. ma, v•s. ; • You must describe how you established the high ground water elevation: " �l.sed: C�a/z —/'�s -1 ,-16�L9-6 G2ound wate2 ePevat.i.on� 'ag6ve eci ' Yeve . 7.6ed: LISGS: we.e.2 data ,Zone 1992 'lied; CISGS 7echnc 2 tg t.cn 9Z-000- 1 ��2at 2 nnua2 Zan e� 0 2ound watea e eva t.on.6. aanua/zy 1992 - t •:cct + Groundwater: Feet Below Bottom of Pi f a I - t High Groundwater Adjustment 1.8 ft per Frimpter Method t i Therefore, the vertical separation distance between the bort,9,= Of the leaching pit and the adjusted groundwater table is . Q) feet. - 1 3 y.•awn.•+.-n.wr-rr- �rwn•nnnT�..t rrtr�rR.-.�rr++�►rww�.nn r�y��n�n �-�.�r-..t..r..,' 1 TOWN OF BQ2n.s.tal 2e WARD OF HEALTH J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPRCTION FORM - PART D •- CERTIFICATION •••1••9�T••••.fir-r. f.-..:rrt+trlw-n.1rf T91r+rRlrsw'R7•i:r}•i rtvin:t s'R7r-Trlw*�w�rR+�n�7Yt1 �r Yrarrr•r--- . _..A -TYPE OR PRINT CLEAALY- PIIOPERTY INSPECTED STREET ADDRESS 16 Ice House 'Road ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Ro&eat & -S,uzan Sehaadea PART D CERTIFICATION t. NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J P Macomber & Son In(:5" j COMPANY ADDRESS Box 66 Centerville Mass. 02632 Stravt Town or City state LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578 m CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one . ,►,,, i• �S y stem PASSED i, i The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public heRltll or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED# c � The inspection which I have con tcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as `specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Dat ON e copy of this ertification must be provided to the OWNER, the BUYER 7* where applicable ) and the BOARD OF HBAL111. * If the inspection FAILED, the owner or"'*operator shall u pgrade ' the eyatem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 C�IR 16 , 305 .. pactd .doc i 2 2— Ex\yT1U!j O Op uP m 1 O O PAw1EL""F II�EPrA'}$D OI ` O OOPa. DooRWAy �� STU61"O/OFF'IGE - ,�, , TO Ad GMP/ED ,- N N TO AGOMMODATm - 5TA\Awr.`t 14 Ew I C1 LT. O ��^ 'Fkls voovi rr TINS NE`N STEEL.BE 4M „(J o O O m FIF�5T FLOOD, PLAN 221_0, SEGO-D-FLOOF�. PLAN '• scA�c �4�1a1,_0, Ir 1 GE 1-:�U�L u.l.lt ' BAPN�r.1E.11=�M.L �LOOP> Pl_Ah! S P►r>`wN bi C)-j .14 o ' ^.M.I.niGuti:EWICZ DATE 3_qq TOWN OF BARNSTABLE r _ LOCATION S Ck, ;9,eJ L- SEWAGE # VILLAGE ASSESSOR'S MAP & LOTb3-L4-63 INSTALLER'S NAME& PHONE NO. �' SEPTIC TANK CAPACITY /f � l„�, LEACHING FACILITY: (type) �5�1 1 (size) NO.OF BEDROOMS �J BUILDER OR OWNER �, �dbC"", c 9 DATE: s' PERMTTDATE: .� - COMPLIANCE Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ,j ASSESSORS MAP NO• 2 - �,���<� PARCEL N0 -__--- ._.__..... : --® No. Fr ............ -�:..... THE COMMONWEALTH OF-MASSACHUSETTS BOARD' OF HEALTH TOWN OF BARNSTABLE Appliration for Di-tipniul Wmrbi Tomitrnrtign Puma Application is hereby-made for a Permit-to Construct (,-I or Repair ( ) an Individual Sewage Disposal System at: ..- ----------------------------•-•-----•-------•---------•-----•----•---....._•--•-••---•----------- Location-:address or Lot No. 1///2-I A//,I L. W4aZLIW/O e_-I'- ----------- Address Installer Address d Type of Building Size Lot-----------_...........Sq. feet Dwelling— No. of Bedrooms_-._______^r3______________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures ----------------- ------------ --- - -- W Design Flow.._...._._._______________________gallons per person per day.. Total daily flow.._.......3 �__.___.____.___.___..gallons. WSeptic Tank—Liquid capacity-!a45_.galIons Length_g_`G_.�.____ Width_4.6--�---.. Diameter----------------- Depth_a'&"J- x Disposal Trench—No- -----fir............ Width_____ � Total Length------ z_.._____ Total leaching area......294�...sq. ft. Seepage Pit No-------------.------- Diameter____________________ Depth below inlet____________________ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by..... ___/-_.:...!�5�6rv/.............. Date__M! / _ �cl�B - i-------------------- as Test Pit No. 1__G_. ....minutes per inch Depth of Test Pit---f. F........ Depth to ground water----—_______.... ri, Test Pit No. 2... _-_minutes per inch Depth of Test Pit------ Depth to ground water........................ a -----------------�-r-----------------------------------------------••---•-•-•------•-•-------..__.._........................................................... x �/✓�3 �� .... S418_ J�?7i✓&Description of Soil._: 4._.__ r` ���� AboDLp�.�y � �fia 5ai� U ..---_ ._._. _ . --- • ...... _. SGr�i✓GS__ -•------Al U Nature of Repairs or Alterations—Answer when applicable......................................__-_._________.__.__...____.._.....,__._.____._.________.. --------•--------------------•---=--------------------------------------------------•---•-------._...--------------------------------------------...__......----------•--------_•---••---............._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The and igne urther agrees not to place the system in operation until a Certificate of Compliance h b a r of health. Signed - -------- - ,�•� Dare - Application.Approved B - -- ---"......... ...... ........... ... '..._.. -- --------------------- -----"....-------------------------- �"•--- Date Application Disapproved for the following rea.rons: .------------------------------------- ------- -----------------......--------...-----.------------------------------------ ... ce Permit No. ��. . .:�,... _ Issued =�d- �� Date THE COMMONWEALTH OF MASSACH'USETTS BOARD OF HEALTH 41 TOWN OF BARNSTABLE !Appliration for Divi-p n ial lVark5 Cnomitrur#io' u ramit Application is hereby make for a Permit to Construct (Vl� or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. i ?u�••tv_ I /N/A..._4=-..Wav/-L--.I'z�.... •-------•--......B,ai2,./ST ............................................. ........ O n , Address --`--- ----------------------- ........................................................... . ----------•--------•---•...._•--•-- Installer Address UType of Building Size Lot.'._-�'_ _ .>r . S_/.._.._ q. feet Dwelling—,No. of Bedrooms__._.____•��_______________________ ...... Attic ( ) Garbage :Grinder ( ) p, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) . "`Cafeteria ( dOther fixtures ......... --------------------------------- --------- ---- •-------------------- W Design Flow_..._....__-S�r.......................gallons per person per day. Total daily flow.__:_.-.-_. 0......................gallons. R: \Septic Tank—Liquid capacity-_ 000gallons Length_$._'�_'�.____ Width-��6'i---- Diameter__'�----------- Deptli_s_8_".. Disposal Trench—No. -----z-........... Width....../.ZZ....... Total Length-------7Z._...... Total leaching rea.-_--_`�$R---sq. ft. Seepage Pit No--------------_---- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by......S;PW _-_4 _.emu-�G�`.............. Date.--!y�__.�' J..............•..... ,�. Test Pit No. L.�..8_---minutes per inch Depth of Test Pit--_1j?..__.... Depth to ground water........... (i Test Pit No. 2.._-:L 8___nainutes per inch Depth of Test Pit----- Depth to ground water."---_--__--_-•---. 11 R+' / -----•------------------------------------------------ ----------•-----•-••-•-•-•--.........-----..........---•-------._...•--------•----.....__...---...... 0 Description of Soil..#/......9..'=Z" '�_i!�! d _ _.SvB-S41G.---.-Z4"-/3Z" -�7 n f v -.S'/�_-1_Z> vi7W Vi /.�/ ...... z �?".�18" INbUDIa�t _. is(ll$�$o/(--•-•- ii B��i � 5�_�NN.. /,*G� A/cc�-y 1WX 8'4:: l _��•�� _ /?sr •y = S.4—,o r ur r.........y....... V Nature of Repairs or Alterations Answer when applicable..-........... .._...._..._._......._........................................................... •------------------------------•--------------- -----------•------------------------•---.-_------------------------------------------------------------------------------------------------------.------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal 'System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned agrees not to place the system in operation until a Certificate of Compliance ha been issue b the"boaCd of health. I Signed----- --- - -------=................. - ..........- ------------------------------- /` Dare—Application,Approved B ......... ........ ... ........ ... .................... ... Dace Application Disapproved for the following reasons- -------------------- --------------_- __-----------------------_ -----------------------------------_-------------- ........ ..... ........ ....................... - - ------------------- - - .....--- ---------------------------------------- - ------------- ------------------- Dace Permit No. .. ............. Issued ..... - Dare ——,a®®—...--------.---------------- z.>c...�,.... THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH f TOWN OF BARNSTABLE U Profit to of ILTTumplianve THIS IS TO CE. TIFY, That the Individual Sewage D'sposal�S/sten- constructed ( ✓ ) or Repaired ( ) I--- at ...../�. .�f G ./ 1 f'...... ./ J C.*.....--- -------------------------------------------------- has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .._., -. �ht dated - THE ISSUANCE OF THIS CERTIFICATE SHALL NO B CON R A GUARANTEE THAT THe SYSTEM WILL FUNCTION SATISFACTORY. ,�.✓ DATE........................ ....-..)...?�. ---- -- ------------------------- ------- Inspector .. d_ ._ _ .. ......_._.......... - - —'----f---,...r.---. _.r•^ ��THE COMMONWEALTH OF MASSACHUSETTS �RJ����_'— �,� �._,_.,e_.�_._,BOARD OF HEALTH TOWN OF BARNSTABLE No l::��.....••--•--* FEs Rapoiittl Works �u�t r�tr#i�n er�tit . 1�=�.Q .r3... r D 1 ..-/�3 Permission is hereby granted--------- .��__..�------- ------------• C'�_.�_..�_--:_'-----...---------------------............ --------•----..._.. to Construct ( / or Repair ( ) an Individual Sewage Disposal System atNo......./1_........ -.............. �' ............................................ Street �,- asishown on the application for Disposal Works Construction Permit r.�; �--- Dated-----�' /r Board-of Health DATE-------------------------------------------------------------------------------- v FORM 38808 HOBBS B WARREN.INC..PUBLISHERS w � v l h 4 © o �� 6'r f ,� tTOWN OF BARNSTABLE LOCATION I C C. t - j L SEWAGE # VILLAGE_ Gil i.}„�.._r �, ASSESSOR'S MAP & LOTc INSTALLER'S NAME&PHONE NO. •—���c>�ii. ��,�'�=.�j`� SEPTIC TANK CAPACITY /l � LEACHING FACILITY: (type) (size) j NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: -2. — 9 COMPLIANCE DATE:_ -Mx.' 1 ,9 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by EL.- 9� MoJrE- RNy vN�t��n++dGEz /�IM'C7��At. /M 77�IiF' Lwc.H /- qC A Art n �itVE �C-' r C d y'ai:r off.' aC 4- TOP Cr FOUNDATION ION �i DE s T3 �G- tc�h >V�T_• ,9r�G .�'/�Ac�L '.- CONCRETE COVERS w.n✓ C9- OZ6 30 ,Q :,a' '�. 4"CA5T IRON OR SCHEDULE 40 �y_ r1 4"SCHEDULE 40 PV.C. (ONLY) ` 9"MIN . LEACHING TRENCH (/ )REO 35„ ra^X r1 �jVy �7 '!A P.V.C. PIPE MIN. r ►;, _ �- PIPE-- 1/8"- 1/2 WASHED STONE to ; - L PITCH 1/4 P-R , I r �jQ� � PITCH �F` .� rI �•; ' :` / `- O %oC7',O;Q,;[n ..��' as'p 24DIST " / w�J/ ' (GSEPTIC TANK _Jct.' BOX j INVErtT L_�S�C'_-G- - Precast 500 Gal.Leach 3/4"-11/2"-/ ` ,r �f , 1' ti ... (.3) REQ. Chamber WASHED STONE :4�17•. 149 5" CRUSHED STQEjE E I• /,'i 0 ` -� •� I 1 - _. ._..- _pz ey Wi>?C k.� GC V•�L - -� yam` GROUND WATER TA3LE y�-` SEWAGE DISPOSAI SYS ► E`1 SOIL LOG YPICAL CROSSsE.TION A U LEACH I NG TRENCH �� 1���' °,� �� t c"'��"' DATE Mpy4 �y •� T;.'AE`/C . ��`�. WL n/h l Ftli,.w' NO S_A_= 1'r Y � �/ MArrm.1.1- /�Cc.N<� t,l� / �vN p C Homer !c TEST �C' I TEST HO' 3 ;.. rEsr µ��L q c " DESIGN D-A1 l •„ o ELEV. . /.`'.. . . ELcv. .37-/.P. . . Z 9 I �S N. 1/3 -I/2." + $O�NN!!` I v -5-=7 36"MAx WooD�Goyry WavDL�Af+ r v ~� f Svg-Sail /�f, $ TG-,.ZL ESTIM47ED FLOW . . . �"' GALLONS/DAY � �—_ - ' N � ' �i +'v �gr3� Q•� v' 4 '�L��t?y�' ' 7NW"' z 1 , 'x SiTTv.1 L= `:i AREA . . i.. . SQ.: i./ ^nENC'i/.. pr L7.'C] ' 24' ,�( I t%j�S D SIDE LEACXiNG AREA . . . . z. . SQ., i./THENCH/loa.�'3 aag� GARBAGE DISPOSAL!�v.N4 (5G% AREA INCREASE) - +. 'aC 3O. [a T:;,''L LE,C- �G ARE • SII• SG? .: SQ.=T. Y4 r lnfrt7/ Nl+t�cGr'plod S. ?ERCOLATICN P..A,E�` r1;: �' M��r/ PER. Ir:C:i -/'fo'.. '/ v z-2-f .` r HNC "= ` / ►� LEACHING AREA -R PER^^ - " -- r/ s,14T/L c ,_ , � �. ✓r.of3$v.?�� GROUND •N.„,7R T:, - y' PoaD 1 �.�O.yo /44" �� o APPROVE) . . . . . . . . . . . . .. KA?.D Cr HEA� H //. �/7 v .NO ..'r -_ ENC0UNT_R�D pA-- !` H• _tiT OR 1NSP=:TOR �!�" 48 WITNESSED BY '. v f> �K�� ,14Rp- . . .�.VA11 t1G a0:,R0 Or HEALT'r� ® f-�s1. \ n \ � M f111L' CoIvsrlZucTiu�t! �4C - ,. - Z iy!► G gov r 5 1 �� ! 1 p 4n �x To�L 46 r + I /awl A1 41 a Y L OIL S MAT) -iCi?G.L I /C� �, .. . / - r, /riY i•t .' I C.. , r s ` FAY. _6Z /�1/ 54? F 7-, ` - �1` ``` r /ao �vl�✓s �� ,,7 / l J-�//a L/-�f`'- - s FRa^s war -517 A/ k\1 dL / `%�7J l ZIA fL I Mtn �`l J�� / 2. �'v � �V•�•, � ••v �HOFA OF EDWARD E. I .B>,e 2—37 iY7f1,; �G /j� 0 .� :�� KELLEY "' No. 26100 eg AECtSTER�� S �pQ J E.z? s/ L �t.M�� ►i EVA uAt° LL-"LG L = �. c�0 n/4: VIA