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HomeMy WebLinkAbout2514 MAIN ST./RTE 6A(BARN.) - Health `.~: '2514 Main Street Barnstable . ", o r a c Commonwealth of Massachusetts o? 00L f Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, Michael Sears use only the tab key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path Q Company Address South Yarmouth Ma. 02664 Cityrrown State Zip Code 508-477-8877 S114430 Telephone Number t 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 N\X��N OF 2. ❑ Conditionally Passes MICHAEL :m% 3. ❑ Needs Further Evaluation by the Local Approving Authority SEARS No.SI14430 4. ❑ Fails IN ��hnnnnnnutt���� 5-11-21 Inspector's 5 ature 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. 1 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 Title 5 Official Inspection Form = FIo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is Barnstable Ma. 02668 5-11-21 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 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 is in working order 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): l5insp-doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2514 Main St. (Rt 6A) V Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. Citylrown 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 ' FIo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11721 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) , i ❑ 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. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. I . ❑ 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: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"'or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 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 .I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma 02668 5-11-21 page. Cityfrown .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 ❑ ® Liquid depth in cesspool 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 of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ - ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Mio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont) If you have answered "yes"to any question,in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for 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 rprevious two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of breakout? ® ❑ Were all system'components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® 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 ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is BarnstableMa. 02668 5-11-21 required for every page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 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 years usage (gpd)): 2019- 38000 gal2020-38000 gal Detail = Sump pump? ❑ Yes ® No Last date of occupancy: NA .Date l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7,of 18 ' Commonwealth of Massachusetts �= l Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `u 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. City/Town 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.1/26/2118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. Cityrrown 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: 9-11-90 #90-409 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 24" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 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 II Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L u 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 r If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 2„ Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Sludge judge, tape, plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with tee inlet and baffle outlet in place, inlet cover 14" below grade ' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Fora I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is Barnstable Ma. 02668 5-11-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date r Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts • Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. Cityrrown 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 with 1 outlet pipe, cover at 24" below grade 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 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): . Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits z number: 1 ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. City/Town 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.): SAS is a 1000 gal pit, pit has wet bottom with stain line at 3' below inlet line and shows no sign of failure 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- ^I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.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 2514 Main St. (Rt 6A) Property Address Julie Jones _ Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 - - ---.-- 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 [0- j 0 _k__0_ I � 3 .A 13 I$,1f f OF�jq M,gS 3_11 MICHAEL ,yG q-3I moo; SEARS _ *.. No.SI14430 rf q,�i'tC S•I N SP�G`````�� } . ��nrnnnn111t�q<<�� 6A t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is Barnstable Ma. 02668 5-11-21 required for every page. Cityrrown 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: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand augered 4' below SAS with no ground water 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 Y Commonwealth of Massachusetts p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 2514 Main St. (Rt 6A) Property Address Julie Jones Owner Owner's Name information is required for every Barnstable Ma. 02668 5-11-21 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 G ortd m o; SAS y° A/c G�;.•w(wa¢� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE .r-CATION SEWAGE # 409 VILLAGE ASSESSOR'S MAP & LOT7-aOy INSTALLER'S NAME & PHONE NO. al® G>DC y3 cF SEPTIC TANK CAPACITY /D©D s Icti/. LEACHING FACILITY:(type) �;T (size) /6 NO. OF BEDROOMS PRIVATE WELL O LIC WAT BUILDER OR OWNER DATE PERMIT ISSUED: Q 9D DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No '� ' �� G1 I �� . �. �,� -� ti. r.y e ��,` r� .. _ ��_ � J .. ... THE COMMONWEALTH OF MASSACHU TTS BOARD OF 4- H TOWN OF BARI :OT BLE Appliration for Disposal Wor Tonstrnrtiun Famit Application is hereby made for a Permit to onstruct ) or Repair (L <<Y an Individual Sewage Disposal System at: elo �r 15 ' .�--•--..__.....L ration-Address o t No. Owner ddress G.0/..I�S7... 7loS� .�1 . ..r� . �'r-��_ ............ Installer Address 7 U Type of Building Size Lot 42 _---Sq. feet �-� Dwelling—No. of Bedrooms......................3...................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------------•-----•---•--------------------------------------------.....----------....-••---..........-•--------•..........--•-- W Design Flow................. -------------gallons per person per day. Total daily flow............. ��........._......gallons. WSeptic Tank—Liquid capacityZ4AW-.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........../__....... Diameter----ZQ----.... Depth below inlet......(........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by................. ........................................................ Date........................................ a Test Pit No. 1----------------minutes per inch Depth of Tes Pit_................... Depth to ground water------------------------ f� Test Pit No. 2________________minutes per inch epth of le Pit_.................... Depth to ground water.___._.............._.._ R+' ......... ---•- ........ ----------••••••••--•••••......................................................... 0 Description of Soil.................................................... ...... .. .. --------------------•----------------------------------------•------------•-..._.. W --------------------------------------------------------------------------------- ---- -- ...................................................................... x --------------------------------•-----------------------------------------------•-----•---•---- :---- -----------------•----------------------•---------------------------•--•------------------- Nature of Repairs or Alterations—Answer w I ble.__�c�o eN___01F- --0o4S r U P ,� 1 Tf.¢vti?4... ._.,D._.e��Q��l .l(1Aa --�-----•����s�'�� ------------------- 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 further agrees not to place the system in operation until a Certificate of Complian has been iss d b he board of ealth. Signed .. � .... ......................................... .......... /9 �,-�p.-- -..�........ Application Approved BY - - Ill ---- --t� ---------------------------------------------------------- I?ace Application Disapproved for the following reasons- ------------------ -- --- -- --- ------------------------------------------------------------------------- -- -------------- ---------------------------------------------------------- -- -------------------------------------- ------------------------ ------------------------------------------------------------------------ --------------------------------------- Zf D Dace Permit No. Issued Dace & j THE COMMONWEALTH OF MASSACH US ETTS 9 BOARD OF HEALTH TOWN OF BARNSTABBLE Appliratiun for Uispusa1 Wor ,s Tomitrurtinn ramit Application is hereby made for a Permit to Construe( ) or Repair (N)' an Individual Sewage Disposal System at: ) �- •--- :��.............-� /�t J-----sue - �- �t/ -•----------S%� � ------------------------------------------------------------------ '� '-.-•-.•••or t No. . _.. � 1� ............................. Owner Address w 2__ afar ..... .... .......... Installer� Address y.. UType of Building Size Lot Q :77:....Sq. feet .., Dwelling—No. of Bedrooms....................S...................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---.-_______-_--_--_----__ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------- = -------------------------------------------------•--------------.........•----......._....... W D,ign Flow..................5 ..............gallons per person per day. Total daily flo•.v________.._--_�3Q ................gallons. WSeptic Tank—Liquid capacity �A�.gallons Length................ Width................ Diameter_______________. Depth___.____._._.__. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........../------- Diameter..---/_-�....... Depth below inlet......4.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.._................. Depth to ground water--_____-___-__-_-------. �T4 Test Pit No. 2................minutes per inch I epth of Test Pit................... Depth to ground water......................... •---------------------------------------- --------•-----••------........................................................................................... Descriptionof Soil.....................................................-------- ...... ....---f/..............` U --------------------•-------------•---....-----------•---------••-•--•••--•--•------.--------- •---v �.--- --....... -----•••••-------------••-•------------•----------•••--•-•------------- W UNature of Repairs or Alterations—Answer w appl'cable__r8ft�vD_aN-_ 'FS_sPvO[S '�'�s%!` �.._1Gl�?�aO / •- �%� f�_ f� X ._/l1ap '.. G`� �` - --- -- •------ Agreement-. t � } l 0 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 further agrees not to place the system in operation until a Certificate of Complian�has een-is b rhe-board-ef health. Signe ..---... --------------------------- ---------------s ----- Application Approved BY ------- Application ----�� ------� --- ---------------------------------------------------------------- Dare Disapprovedfor the following reasons• -------------------------------------------------------------------------------------------------------------------------------------- ------- ----------------------.................... ----------------------------------------------- ----------------------------------------------------------------------------------------------- --------------------------------------- �J 7 1� �/ G Permit No. / Dare Issued ------------ Date THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE Certifirate of Tompltttnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (p� by.............................................. rr7 ..... 'a vsT iU L --- ---------------------------------------------................. Installer at . y -,/yl �nl.-. ��-----TL ..�r� 4..----- ,C�� i9 GE has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..... .. -..�-.... --Q--- ----------- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-----........................ r� - - ....... Inspector s _ ..... G7r 7 DDy THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.....[..�---�G� FEE. _.-...... Disposal Workii C�unfriun rrntit Permission is hereby granted .. 0?77 , .---- -•--------•-•--•-...--.---------.....+ Ql� r _C. to Construct ( ) or Repair (�X) an Individual Sewage Di s aSal System at No................. . ...�......-.... .1-�f/ --------1. .....1't'' f ............... Street ¢c� as shown on the application for Disposal Works Construction Permit No.2'0_..O Dated.......................................... Board of Eealth DATE................................................................................ FORM 36508 HOBBS&WARREN,INC..PUBLISHERS 5/4/2021 ShowAsbuilt(1700x2800) TOWN OF BARNSTABLE OCAT101J S/Y elf,�A) SST SEWAGE# po VILLAGE i l ASSESSOR'S MAP&LOT-;�S7-60y INSTAL �R'S ME&PHONE NO.k�2 epTl1 aoAsT y 8 SEPTIC TANK ACITY ,,24,0 SkO LEACHING FACILITY:(type) PiT !✓�(si`z�e)',�xiQ� NO.OF BEDROOMS PRIVATE WELL OR�7]BLIC W R (' .BUILDER OR OWNER r19U� DATE PERMIT ISSUED: /G/iy/9p DATE COMPLIANCE ISSUED; /L,j'-70 VARIANCE GRANTED: Yes No i 0 I https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=257004&sq=1 1/1 TOWN OF BARNSTABLE LOCATION Xyl � Math 5 \4AarLL�bjgSEWAGE # VILLAGE ;y h 5}nl��p� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. y ray' SEPTIC TANK CAPACITY i ,-U0 d qa LEACHING FACILITY:(type) If D0 1 eGckre (sue) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER LAW-`C1e2 I` \414v, DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: uynj3 �^?eU -le VARIANCE GRANTED: Yes No 0� ��.