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Home My WebLink About0017 INDIAN TRAIL - Health (2) J 7 Ind ian Tr�11- Barnstable A= 335-019 Commonwealth of Massachusetts ` Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is q required for every Cumma uid MA 02630 December 2, 2009 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 fortes A. General Information k on the computer, � use only the tab p - / �: � key to move your 1. Ins ector: cursor-do not David D. Flaherty Jr., R.S. ; p use key the return Name of Inspector Flaherty Environmental services 0 Company Name P.O. Box 81 4i Company Address r" r Yarmouth Port MA _ g 2675 Cityfrown State Zip Code 508-362-1657 S14713 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site 1 sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority bf,4J December 3, 2009 Inspector's Signature V 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•09108 Title 5 Official Inspection F Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name umma4 formation is C uid MA 02630 December 2, 2009 squired for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as de ribed in the"Conditional Pass"section need to be replaced or repaired. The system, up completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"no etermined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and er 20 years old' or the septic tank(whether metal or not) is structurally unsound, exhibits substanti infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing nk is replaced with a complying septic tank as approved by the Board of Health. A metal septic to will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indi ting that the tank is less than 20 years old is available. ❑ Y N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Ford Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is Cumma uid MA 02630 December 2, 2009 required for every q _ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cone.): ❑ 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 distributio box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N, ❑ N Explain below): ❑ obstruction is removed ❑ Y ❑ N ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ ❑ ND (Explain below): ❑ The system required pumping more than times a year due to broken or obstructed pipe(s). The system will pass inspection if(with app val of the Board of Health): , ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed '❑-Y ❑ N ❑ ND (Explain below):. C) /and l ation is Required by the Board of Health: ❑ xist which require further evaluation by the Board of Health in order to determine if is failing to protect public health, safety or the environment. will pass unless Board of Health determines in accordance with 310 CMR )that the system is not functioning in a manner which will protect public health, the environment: spool 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 officinal Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name equined for every q Lion is Cumma uid MA 02630 December 2, 2009 squire page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Suppfrer, if any) determines that the system is functioning in a manner that prote the public health, safety and environment: ❑ The system has a septic tank and soil absorption sys (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface ter supply. ❑ The system has a septic tank and SAS and the AS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS an the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and 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 wa r analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. I D) 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 El ® . 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 Y2 day flow l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is Cummaquid MA 02630 December 2, 2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A.copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the'above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system m 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 ch of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 f t of a,surface,drinking water supply ❑ ❑ . the system is within 0 feet of a tributary to a surface drinking water supply El' El the system is to ted in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA r a mapped Zone II of a public water supply well If you have answered"yes"to a question in Section E the system is considered a significant threat, or answered"yes" in Section above the large system has failed. The owner or operator of any large system considered a signi nt threat under Section E or failed under Section D shall upgrade the system in accordance ' 310 CMR 15.304. The system owner should contact the appropriate regional office of th epartment. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is required for every 4 Cumma uid MA 02630 December 2, 2009 , 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 approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins-09/08 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 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is Cummaquid > MA 02630 December 2, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ 'Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d '08: 159 gpd;'09: 9 ( Y 9 (gpd)): 83 gpd Detail Sump pump? ❑ Yes ® No Last date of occupancy: present(part- time) 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., ): Grease trap present? ❑ Yes ❑ No industrial waste holding tank pres nt? ❑ .Yes ❑ No Non-sanitary waste discharg to the Title 5 system? ❑ Yes ❑ No Water meter readings, if ailable: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I` ` Commonwealth of Massachusetts , Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is q required for every Cumma uid MA 02630 December 2, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: bate Other(describe below): General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ®. No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ 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•09/08InspectionTitle 5 Official Fom.Subsurface Sewage Disposal System-Page 8 of 17 V Commonwealth of Massachusetts Title 5 official. Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name q formation is Cumma uid MA 02630 December 2, 2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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.):, joints good, venting through house adequate, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: - 1500 gallon Sludge depth: 811 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts ~ Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is required for every Cummaquid MA 02630 December 2, 2009 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 26" - 4" Scum thickness 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 1011 How were dimensions determined? tape measure, stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): maintenance pumping recommended at this time, inlet&outlet tees in good shape, tank seems structurally sound, liquid level apprpriate, no evidence of leakage Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ' ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene [],other(explain): Dimensions: Scum thickness Distance from top scum to top of outlet tee or baffle Distance fro ottom of scum to bottom of outlet tee or baffle Date of I st pumping: Date . t5ins-09/08 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 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is q required for every Cumma uid MA 02630 December 2, 2009 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped a/sEE11 te on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fibylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(cond' on of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑. Yes ❑ No t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is Cumma uid MA 02630 December 2, 2009 required for every q _ 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 n/a 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.): primary dbox in good working order, no sign of backup or hydraulic failure; secondary dbox(bull run valve box) has all parts in working order, cleared minor root infiltration, lines out seem to be equal (both sides open at this time) 4 Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, c/hofps and appurtenances, etc.): Soil Absorption Syste (SAS) (locate on site plan, excavation not required): If SAS not located, plain why: i t5ins•09108 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 12 of 17 Commonwealth of Massachusetts m Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is Cummaquid MA' 02630 December 2, 2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: each ❑ 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.): no signs of breakout or hydraulic failure, vegetation typical(lawn and garden) Cesspools(cesspool must be pumped as rt of inspection) (locate on site plan)- Number and configuration Depth—top of liquid to inlet inve Depth of solids layer Depth of scum layer , Dimensions of ce pool Materials of nstruction Indicati of groundwater inflow ❑ Yes ❑ No . t5ins-09/08 Title 5 Moat Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is Cummaguid MA 02630 December 2, 2009 required for every page. Citylrown 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.): T I Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of so/�yaulic failure, level of ponding, condition of vegetation, etc.): t5ins•0908 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is required for every Cummaguid MA 02630 December 2,2009 page. Cityrrown 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 OV �'��3 I� a, - sy- �'Z ' `( 0 t4l'3 521 G /f � - /0 9 . tsins•09f08 Title 5 Official loon Form:subsurface Dis posal sposal system•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form- Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owner's Name information is Cummaguid MA 02630 December 2, 2009 required for every page. City/Town 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: >10feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) . ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: hand augered to 9', no groundwater encountered Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 v r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Indian Trail Property Address Thomas Shanahan Owner Owners Name information is required for every Cummaguid MA 02630 December 2, 2009 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09108 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System.-Page 17 of 17 TOWN OF BARNSTABLE LOCATION /-7 SEWAGE#"�-To-, cW-T00- VILLAGE w MM01%u,,d ASSESSOR'S MAP&PARCEL -�-�Je'—O/ fNWJ+AWr,ERS NAME&PHONE N67�6<-11- �oAVJI SEPTIC TANK CAPACITY 4500 LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COIAPi40rNOPE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Foo ' \ all coJ�,� . Per � r� { i Town of Barnstable P T� 74-- - o IHE F row Department of Regulatory Services L� Public Health Division Date z BAiU:57A8[? v� 11639 • 200 Main Street,Hyannis MA 02601 prfD!M't� Time FeePd. Date Scheduled 30 O� I �dU , Soil SuitabilityAssessment for Sewage Disposal.. Witnessed By: Perfonned By: ��51 LOCATION & GENERAL INFORMATION Owner's Name S;;_Ptt'2A Location Address I'� S�dc'� t!'ai 1 1 • 6 h 1'1^j-�H.�e Address _ •. Engineer's Name'jwk taG'C• Assessor's Map/Parcel: NEW CONSTRRUM014 REPAIR Telephone# Land Use A/A.,i A w Slopes(%) Surface Stones Q/Lv Distances from: Open Water Body —---— ft Possible Wet Area>�ft . Drinking Water Well . r i - ft ; Drainage Way QQ ft Property Lines—ft Other SICETCI-I:(Street dame,dimensions of lot,exact locations of test JAZ holes&perc tests,locate wetlands in proximity to.holes) t, 2(y fi y 120, 1421 Depth to Bedrock Parent material tgeologic) Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face I)ETERwHNATTON FOR SEASONAL HIGH WATER TABLE Method Used: x �� -VV3 in. Depth to soil mottles: In. Depth Observed standing in obs.hole: ft. in. Groundwater Adjustment Depth to weeping from side of obs.hole: Ad factor _ Adj.Groundwater Level_ Index Well# Reading Date: Index Well level J•- PERCOLATION TEST Date", rTi�„e o' Observation Time at 9" 4% y Hole# 5 Z j Time at 6" — Dcpth of Pere 1 ' Time(9"-b") n`""` Start Pre-soak Time a End Pre-soak Rate Min./Inch —Z-- Site Failed: Additional Testing Needed(vM) Site Suitability Assessment: Site Passed _ — Original: Public Health Division Observation Hole Data To Be Completed on Back— -- ***If percolation test is to be conducted within 100' of wetland,you must first notify the t least one (1)week prior to beginning. Barnstable Conservation Division a Q:HEALTH/W P/PERCFO RM DEEP OBSERVATION HOLE LOG Hole#_J- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(In.) . (USDA) (Munsoll) Mottling (Structure,Stones,Boulders. Conslstenov,°/a Gravell._..._._.- o -iz O sl/� �o�•c 12 Z`!� Si 4 ..,fir roG' ,�,Q „ l�6 t • DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) rl /rJYA „ DEEP OBSERVATION HOLE LOG Hole# 3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency %Gravel) qA s'Lcxu/l ; � (a ti Lt �, Loa"i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texturp Soil Color ,}-5 Soil Other Surface(in.) (VA) (Munsell) Mottling (Stricture,Stones,Boulders. Sa �r Consistency.%Gravel) /G L Z.sy c s + _ 7Z c S. L w+ /oy1 / to yr�'�y OR o .L.IO /l G 9 �v ua .evlc. 16 r0 SL ` 16Y26 6 y ' do AW _ � /q r n� 9A e4te, Flood Insurance hate Ma n: � No�,' f/�it,pA '� �/art Above 500 year flood boundary No— Yes Within 500 year boundary No_—. Yes 9 .within 100 year flood boundary No yes De th of Natural! Occurrin Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? 6i� • If not,what is the depth,of naturally occurring Yervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of 130 irontn ntal Protection and that the above analysis was performed by me consistent with the required training,expertise and experience d ribed in 310 C1vfR I.5.017. rovil v�"1 Date G �G 0 �LdItR-2GI�0 Few Signature ' 0 t Q-.HEALTH/W P/PERCrORM t' Town of Barnstable P# l 7 7 16 P�pFTHETpkp Department of Regulatory Services Public Health Division Date BABNsrABLE• ' .•,:'l. .: 4 y 6 200 Main Street,Hyannis MA 02601. / r; 30 OL Time 11 A 1\ Fee PA.' Date Scheduled ` (w , w Soil.Suitability-Assessment for;5'W`i dge,DisPosah, , Performed By: Witnessed By: � LOCATION & GENERAL INFORMATION Location Address 17 Owner's Name S';�,p n s Address ql Engineer's Name ,wn Assessor's Map/Parcel: 3 35-41 NEW CONSTRUCTION REPAIR Telephone#, P/ i rK'. Land Use �lp i�� .1'�� Slopes(1/0) Q Surface Stones ft Drinking Water Well •N `it^ `` 4, Distances from: Open Water Body ,ft Possible Wet Area _ ,, ti Drainage Way Utz / ft Property Line �O ft Other ` SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to•holes) � f UP( Y. Parent material(geologic)' ,`: :'t Depth to Bedrock Depth `to Groundwater:,Standing:�!ater,in Hole:4k*I Weeping from Pit Face Estimated Seasonal High Groundwater , DETERMINATION,FORMASONAL HIGH WATER TABLE Method Used: in. Depth Observed standing in obs:Bole: ?tom/ in. Depth to soil mottles: in. Groundwater Adjustment R Depth to weeping from side of obs.hole: _ Jra factor---.- .Groundwater Level_ Index Well# Reading Date:- � „` index Well level --_ - A • Ad•� PERCOLATION TEST Date /6 Time O Observation ITime at 9" Hole# D: 5 Depth of Perc 1! l Time at 6" Al-6 Z Start Pre-soak Time Qa f 0:a Time(9"-6") End Pre-soak "•i r c,'.l Rate Min./Inch 3 ^�+• I ,Testing Needed(Y/N) Site Suitability Assessment: Site Passed=- Site Failed: - -,.AdditionalI Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must f rst.notify the Barnstable Con servation Division at least one(1)week prior to beginning- Q:HEALTH/WP/PERCFORM DEEP OBSERVATION HOLE LOG Hole#_ Depth.from Soil Horizon Soil Texture Soil Color Soil Other Surhee(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. comigteng%°laliruvell... ..-- -•. o/z 4 4 A L aw•t. 2ef 7z C DEEP OBSERVATION HOLE LOG Hoie#' 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency %Gravel) tejygyll DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon :Soil Texture Soil Color Soil Other Surface(in.) "� (USDA) (Munsell) ; __Mottling (Structure,Stones,Boulders. Consi.stency.%Gravel) 17 _Z s• Lt �• o /D G 0 r— DEEP OBSERVATION HOLE LOG -Hole# � Other Depth from Soil Horizon S Soil Color Soil AS eA)m (Munse'16 Mottling (Stricture,Stones,Boulders. Surface.(in.) _ f�' Consistenc %Gravel a o- S GM a y/�s/y i..'aH $, �40 c sd► ° � _ 7Z S.L ioyn�� Z X!5 • S, s o4A44 Flood Insurance Rate Man- Yes /VO `P: P 1F0 %NBC Above 500 year flood boundary No_ 1• u �{tA Within 500 year boundary No— Yes I .Within 100 year flood boundaryy No Yes De th of Naturall Occurrin Pervious Material rring pervious material exist in all areas observed throughout the Does at least four feet bflzaturally occu area proposed for the soil absorption system? If not,what is the-depth ofnaturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environm ntal Protection and that the above analysis was performed by rite'consistent with the required training,expertise and experienced ribed in 310 CMR 1.5.017. Dated/ m 0 Y Signature • r Q:HEALTH/WP/PI ERCFORM AX COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION Y F �Q r y� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A s CERTIFICATION - off- Property Address: 17 Indian Trail ' Cummaquid MA 02637 tM Owner's Name: Margurita Simpkins Owner's Address: Same ^� i Date of Inspection: April 13,2006 Job#06-102 C)`i Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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: tniF ►►1��6 _X_ Passes Conditionally Passes ? ! G • PA ICK .cn Needs Further Evaluation b the Local Approving Authority J :M Fail cd Inspector's Signature: Date: 4/13/06 •'•�� •oQ�.�` INSPE��``�� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of H j6 111%��` 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: Tank has liquid only and is not in need of pumping at this time.Leaching trenches show no evidence of backup or saturation. ""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. :. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: 17 Indian Trail,Cummaquid Owner: Margurita Simpkins , Date of Inspection: April 13,2006 Inspection Summary: Check .A,B,C,D or E/ALWAYS complete allot Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the_ for.the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 Indian Trail,Cummaquid Owner: Margurita Simpkins Date of Inspection: April 13,2006 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 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 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: w Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 Indian Trail,Cummaquid Owner: Margurita Simpkins Date of Inspection: April 13,2006 D. System Failure Criteria applicable to all,systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _ _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructedpipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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.] _No_(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• 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 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 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. M Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 Indian Trail,Cummaquid Owner: Margurita Simpkins Date of Inspection: April 13,2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X _ Pumping information was provided by the owner,occupant,or Board of Health _ _X Were any of the system components pumped out in the previous two weeks? _ _X_ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _ _X Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X- _ 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? _X _ 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: Yes no _ _X_ Existing information.For example,a plan at the Board of Health. _X_ _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 Indian Trail,Cummaquid Owner: Margurita Simpkins Date of Inspection: April 13,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): N/A Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):Unknown Number of current residents:0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):No Water meter readings,if available(last 2 years usage(gpd)): None,vacant for two years Sump pump(yes or no): No Last date of occupancy: Two years prior to inspection. COMMERCIALANDUSTRIAL Type of establishment: :.. Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): , GENERAL INFORMATION Pumping Records: Tank pumped in 2000 Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X 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: 1970+/- Were sewage odors detected when arriving at the site(yes or no): No f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Indian Trail,Cummaquid Owner: Margurita Simpkins Date of Inspection: April 13,2006 BUILDING SEWER:XX (locate on site plan) Depth below grade: 2' Materials of construction:_X cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 2' Material of construction:_X_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: 10.5'long x 5.8'wide—1500 gal. Sludge depth: 0" ; Distance from top of sludge to bottom_ of outlet tee or baffle: Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. 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 has liquid only,no sludge or scum lavers.Liquid level at bottom of outlet invert and tees are intact and clear.Recommend pumping tank every three years when under normal use. GREASE TRAP: No (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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Indian Trail,Cummaquid Owner: Margurita Simpkins Date of Inspection: April 13,2006 TIGHT or HOLDING TANK: No (tank must be pumped 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: Qallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Box is structurally sound with no evidence of leaks.Box is equipped with slide gates to alternate flow from one trench to other and has been alternated monthly since system was installed Keeyine with this practice will extend the useful life of the leachine system. PUMP CHAMBER: No (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.): f Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Indian Trail,Cummaquid Owner: Margurita Simpkins Date of Inspection: April 13,2006 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type e leaching pits,number: leaching chambers,number: leaching galleries,number: _X_leaching trenches,number, length:2 @ 60'+/- 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.): Trenches show no evidence of backua or saturation.Vegetation and soils are normal. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Indian Trail,Cummaquid µ Owner: Margurita Simpkins Date of Inspection: April 13,2006 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. ■ On ran Trail Water Service Ret. Wall C/1 covers @ grade . 3 Page 11 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) Property Address: 17 Indian Trail,Cummaquid Owner: Margurita Simpkins Date of Inspection: April 13,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 10 feet Please indicate(check)all methods used to determine the high ground water elevation: < Obtained from system design plans on record-If checked,date of design plan reviewed: _X_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: Low area with occasional surface water(road runoff)abutting property is 8-10'lower than SAS. F i _ 4 ' - COMMONWEALTH OF MASSACHUSETT S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS N b DEPARTMENT OF ENVIRONMENTAL ]PROTECTION MAP ,�P 3 = PARCEL. TITLE 5 EAT -, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Proper ty Address: 17 Indian Trail Cummaquid MA 02637 Owner s Name: Marguerita Simpkins Owner s Address: Same Date of Inspection: January 31,2004 F�V /C Fe Name f,f Inspector: PATRICK M.O'CONNELL TOf,I,� �? Comps,,iy Name: SEPTIC INSPECTION SERVICES CO, Mailin;! Address: AD MARS TONS MIL 3 MA 02648 y�R TTge<F Teleph:ne Number: 508-428-1779 CERTIFICATION STATEMENT I certit that I have personally inspected the sewage disposal system at this address and that the information reported below i i true,accurate and complete as of the time of the inspection. The inspection was performed based on my training ind 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: ,�` �H pF Mq _X Passes .� ' .,. .,., 1r►�"S Conditionally Passes Needs Further Evaluation by the Local Approving Authority P RIC t' Fails _ e: M L Inspecl or's Signature: ' dV4 I' Date:_1/3I/04 The sys:cm inspector shall submit a copy of this inspection report to the Approving Authority(Board of H'e DEP)within 30 days of completing this inspection. Ifthe.system is a.shared system or has a design flow of 100,00ttittt++� gpd or 1;.mater,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 authorii-r. Notes ahc.Comments: System in good condition.System has two leaching trenches with a switch gate in d-box alternafei monthly between trenches. ""Tiws report only describes conditions at the time of Inspection and under the conditions of use at that time.Tl,i:,Inspection does not address how the system will perform in the future under the same or different condltion,i of use. Title 5 insliection Form 6/15/2000 page ] ' Page 2 A l l 13FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC.`TION FORM PART A CERTIFICATION(continued) Property Address: 17 Indian Trail,Cummaquid Owner: Margoerita Simpkins. Date o i'Inspection:January 31,2004 Inspec t ion Summary: Check A,B,C,D or E/ALWAY complete all of Section D A. System Passes: _XX I have not found any information which indicates.that any of the failure criteria described in 310 CMR 15.303 it in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comm.:nts: B. Sy:jtem 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. Answei .yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain "lie septic tank is metal and over 20 years old*orThe septic tank(whether metal or not)is structurally unsoun,1, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing i ank is replaced with a complying septic tank as approved by the Board of Health. *A met►i septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicati i;;that the tank is less than 20 years old is available. ND exr Icon: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstruc:ed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND ex€lain: the system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will Pass in,pection if(with approval of the Board of Health): broken pipe(s)are replaced _obstruction is removed ND ext Lehi: Page a )f I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARV ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM PART A CERTIFICATION(continued) iPropei,ty Address: 17 Indian Trail,Cummaquid Owner: Marguerite Simpkins , Date t.'Inspection: January 31,2004 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 2. System will fail unless the Board of Health(and Public Water Supplier,If any)determines that the syst M is functioning In a manner that protects the public health,safety and emvirooment: _ 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 I of 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 160 feet but 50 feet or more from a private water supply well**.Method used to determine distance *This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform I-arteria and volatile organic compounds indicates that the well is fi•ee from pollution from that facility and re presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other I rilure criteria are triggered.A copy of the analysis must be attached to this fornn. 3. (:ether: Page 4 if I 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Propei ty Address: 17 Indian Trail,Cummaquid Owner: Marguerita Simpkins Date c-l'Inspection: January 31,2004 D. Sy item)Failure Criteria applicable to all systems: You w ist indicate"yes"or"no"to each of the following for all inspections: Yes No X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool __X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or. cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _K_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped K_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _K Any portion of a cesspool or privy is within a zone I of a public well. K� Any portion of a cesspool or privy is within 50 feet of a private water supply well. _K_ 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.] _No (Yes/No)The system f,a&.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. Lai ge Systems, To be considered a large system the system must serve a ;facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The fol )wing criteria apply to large systems in addition to the criteria above) 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 If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"hi iection 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. "lie system owner should contact the appropriate regional office of the Department. ;. " • Page A 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 Indian Trail,Cummaquid , Owner: Marguerita Simpkins Date oi'Inspection: January 31,2004 Check:f the following have been done.You must indicate"yes"or"no"as to each of the following: Yes 1 o 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? _X_ __ 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? _X_ _ _ Was the site inspected for signs of break out? _X_ _ ._ Were all system components,excluding the SAS,located on site? X 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? X_ _.__ Was the facility owner(and occupants if different fiom owner)provided with information on the proper mainten.jtice of subsurface sewage disposal systems? The size 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. X_ Determined in the Feld(if any of the failure criteria related to Part C is at issue approximation of distance i!,unacceptable)[310 CMR 15.302(3)(b)] . s Page(i )f l l 13FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Proper ty Address: 17 Indian Trail,Cummaquid Owner: Marguerite Simpkins Date o C Inspection: January 31,2004 FLOW CONDITIONS RESIU ENTIAL Numbe•of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIG.V flow based on 3 10 CMR 15.203(for example: l 10 gpd x#of bedrooms):550 Numbe•of current residents: 1 Does re sidence have a garbage grinder(yes or no): No Is launc.ry on a separate sewage system(yes or no): No (if yes separate inspection required] Laundr,system inspected(yes or no): Seasoni tl use:(yes or no):No Water r ieter readings,if available(last 2 years usage(gpd)): 2002—72,000 gal.2003—67,000 gal.=I"gpd. Sump p ump(yes or no): No Last da a of occupancy: Currently Occupied COMA[ERCIAL/INDUSTRIAL Type of establishment: Design low(based on 3 10 CMR 15.203): gpd Basis o'design flow(seats/persons/sgft,etc.): Grease i rap present(yes or no): Industri:ki waste holding tank present(yes or no): Non-sar itary waste discharged to the Title 5 system(yes or no):, Water v eter readings,if available: Last da::of occupancy/use: OTHE K(describe): GENERAL INFORMATION Pumping;Records: Last pumped 2001 Source(f information: Owner Was sy;:=pumped as part of the inspection(yes or no): No If yes, volume Pumped:um ed P gallons__Haw was quantity pumped determined? Reason 1i)rpumping: TYPE C'F SYSTEM u _X_Septic tank,distribution box,soil absorption system Singla cesspool ____Ove:•.low cesspool _�Pri r/ 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 obtaineJ from system owner) —Tig.h t tank Attach a copy of the DEP approval Other(describe): Approx in irate age of all components,date installed(if known)and source of information: 1!i70+/- Were st;uage odors detected when arriving at the site(yes or no): No N 1 ; Page" 3f l l II FFI CI AL IN SPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Indian Trail,Cummaquid Owner: Marguerita Simpkins Date o t Inspection: January 311,2004 BUILE ING SEWER: X (locate on site plan) Depth l elow grade: V Materie Is of construction: X_cast iron _40 PVC_other(explain): Distanc:from private water supply well or suction line: 24' Comm(ats(on condition of joints,venting,evidence of leakage,etc,): SEPTIC TANK: X (locate on site plan) Depth h;low grade: I8" Materia of construction:X—Concrete metal fiberglass____polyethylene _othc.-(explain) — T If tank metal list certificzr,e) age:__._ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of Dimens ions: 10.5' long x 5.8'wide—1500 gal. Sludge di pth: 1,, Distancu from top of sludge to bottom of outlet tee or baffle:30" Scum tl E i ckness: 21, Distanc( from top of scum to top of outlet tee or baffle: 8" Distanc( from bottom of scum to bottom of outlet tee or baffle: 13" How m ere dimensions determined: STICK WITH HINGE FLAP, Commc rus(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): 13_affles intact and clear Lio uld revel at hottom of outlet n�oe GREAcS E',TRAP: No (locate on site plan) Depth tic hw grade:_ Material of construction: concrete metal fiberglass___polyethylene,other (explain): — _fiberglass `-- Scum thickness:_ Distance fi om top of Scum to top of outlet tee or baffle: Distance fi'om bottom of scum to bottom of outlet tee or ffl�ba e: Date of L•rst pumping: —-- Commc nts(on pumping reconunendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): i, Page 8 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Indian Trail,Cummaquid Owner i Marguerita Simpkins Date of Inspection: January 31,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth t elow grade: Material of construction: concrete metal fiberglass____polyethylene__other(explain): Dimens ons -- - Capach _ gallons Design 7low: gallons/da Y Alarm resent: es I {y or no): Alarm li vel: Alarm in working order(yes or no): Date of ast pumping: Connor nts(condition of alarm and float switches, etc.): DISTRIBUTION BOX:X (if present must be opened) (locate on site plan) 1 Depth o'liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage i)tto or out of box,etc.): ;Bog,set level o solids carry ver.Llauid level at bottom of outlet pipes 1301 has a switch gate to alternalgiLofflMm one trench to the other and has bee Iwltcbedmonthly since system vyas installed PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms i n working order(yes or no). Commertti(note condition of pump chamber,condition of pumps and appurtenances,etc.): i • Page 9 of l i 4 ' °OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Proper ty Address: 17 Indian Trail,Cummaquid Owner: Marguerita Simpkins Date of'inspection: January 31,2004 SOIL E,BSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) -; If SAS lot located explain why; Type le.:ching pits,number: le,lching chambers,number: leaching galleries,number: X lcitching trenches,number,length: Two trenches 60-70 feet long.leaching fields,number, dimensions: ol,t:rflow cesspool,number: innovative/alternative system Type/name of technology: Comm( its(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Area of leac'ing systertt shows no excessive ve or e I en s e ;J RRS no evidence'o� y-� �ofpoZdlne.Area around leaching CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plats) Numbe,end configuration: Depth--bop of liquid to inlet invert: Depth of!iolids layer: Depth o1'scum layer: Dimem i i is of cesspool: Materia I i of construction: Indication of groundwater inflow(yes or no): Comme rit:i(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIVY: rJo (locate on site plan) Material: cf construction: Dimen,ion is Depth of solids: Comm(n is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc;); „ Page b i of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Proper.y Address: 17 Indian Trail,Cummaquid Owner Marguerlta Simpkins Date of Inspection: January 31,2004 a SKET(I•I OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least:two permanent reference'landmarks or, benchrr.irks.Locate all wells wifti 100 feet. Locate where public water supply enters the building. WI' ti r a '4 \ ` 'Y 1�pO C}nA • . , .'fir,w�.11 `. ..• t t n .. . ♦ ... ' { Rye.- +", f r - . • F Page 1 l of I 1 OFFICIAL INSPECTION FORM—' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properi y Address: 17 Indian Trail,Cummaquid Owner: Marguerita Simpkins Date of inspection: January 31,2004 SITE E UNI Slope None Surface water None Check ualar Dry I,f Shallow .wells None Estimated depth to ground water: More than 10 feet Please irulicate(check)all methods used to determine the high ground water elevation: Obt inted from system design plans on record-If checked,date of design plan reviewed: _X—Observed site(abutting property/observation hole within 150 feet of SAS) C i ccked with local Board of Health-explain: C i.-,*ed with local excavators, installers-(attach documentation) A—ossed USGS database-explain: You mint describe how you established the high ground water elevation: Smail area of Intermittent standing water to rear of property approximately 10 feet lower than area of leacl►in t system.beaching area was built up with pere sand at time of installation to separate leaching area 6-7 feet from groundwater. i Search for Map/Parcel 335019 ►' Town of Barnstable in13� 3 �l.o f °�'°twfYc .� l For Parcel Number Rental Property(Y/N): Irl Business Name: zone of Contribution(Y/N): �r- fi Area Number r r� Contaminant Rel(YIN) j 4 Phone: 000 ,. '1000000011, Fuel Storage Tank Permit: Card On File: IF Disposal Works ` Pere Test Well Permit (Construction File/Permit No: Issuance Date: Completion Date: l Size of Septic rr— Type/Size of SAS:ISee inspection reports on file _ � { Tank: Il t ---�— ---- —-- --- ----- Comments: ]VALVE TAG NOS.125&126 19 Indian Trail=335019002. T,� mappar: 335019 f Owner: `SIMPKINS,JOHN JR&MARGUERITA proploc: i 17 INDIAN TRAIL -- E i Innovative/Alternative Technology Septic Systems Single or ____---. - Clustered I/A Type, I/A Service Type i add delete records? I ' f x t I - , « M , • t r�c, 1• T ACC CK1Slfrn �lo� l � ,, fa »., _ • _ _ ^+ � a s ,�qlo 9 lx+shoghreom f t NNI P �• �ioca�e.eX1s� � - 4 • hz4,�rc�/mod � r _ � � F � ' w„,boa °�,,, wc�s�lnq •• .: -. • s , h7A�� as exlsFlr �r� t a��r�q.dy. �� Aid v�wj�lon�l�� ix}>Nc w I „ � • -._i exls+ I i • kArlfion5 . Y. 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