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HomeMy WebLinkAbout2670 MAIN ST./RTE 6A(BARN.) - Health 2670+MainiSt Barnaab�e R - A= 258 -00 i Ili 1) 5 I v O TOWN OF BARNSTABLE LOCATION �'j'f© Ala 's4 S"T SEWAGE# VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO.�/i��s. ii� CEO ✓f� c S'�.a �f SEPTIC TANK CAPACITY /oGo cc•9LZ is coo LEACHING FACILITY.(type) (size) ,2z.6 is dz✓- X /i " NO.OF BEDROOMS BUILDER OR OWNER ortU PERMIT DATE: ,t 0 COMPLIANCE DATE: /m f2o�z o Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility /1I 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 l i 461 W5E vj c l'i Cl E3 013 j 2 3 70� - 5off 700' � °' (3 r 6 I al'7"lo !fir IvT -7 to 369 o 0 0 0 � / 15-'e, " q No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Disposal 6pstrm Construction 3permit Application for a Permit to Construct( ) Repair(!/j Upgrade( ) Abandon( ) Pt/Complete System ❑Individual Components Location Address or Lot No.:76'70 T Owner's Name,Address,and Tel.No. 7 7"/- ,3�<titfad/� �•��� Assessor's Map/Parcel zs�— ood Installer's Name,Address,and Tel.No. ,y-ad0 7 rs= Zo��3 Designer's Name,Address,and Tel.No. vim? �'c.� C'<.4' S��'f<� S�s<.saP�' ��rufr«avfd� ����Besc:ef� •t�ad�f Type of Building: f , Dwelling4 No.of Bedrooms t / 1 Lot Size sq.8. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ;S`„j O gpd Design flow provided ,i��. gpd Plan Date Number of sheets Revision Date Title /Sk 4.sc_ /dG O Size of Septic Tank Type of S.A.S. ` Description of Soil Z'o Nature of Repairs or Alterations(Answer when applicable) •�—Ns�l/ aGew ls'oo ��f T�� d� �: o�r�ot�s _�c� i.�i�o Jr' �� f�i Cee/� ,:Z�Flfsb{ryrS: .Z?. 6' '•,� �.?.,�X !/�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date _9 dzzs Application Approved by Date Application Disapproved by Date for the following reasons Permit No. — Date Issued 9 � No. Fee 'TTHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC'HEALTH DIVISION - TOWN OF„BARNSTABLE, MASSACHUSETTS Yes t I �ILatlon ,for i0I8p08a1, pBtPIYI-Construction Permit Application for a Permit to Construct( ) Repair(64'Upgrade( ) .Abandon( ) [Complete System ❑Individual Components Location Address.or Lot No. 2G To ,,.moo,%z'"f 7" Owner's Name,Address,and Tel.No. -7 r5'­y3 5i-sq yT Assessor's Map/Parcel Desi ner.'s Name,Address,and Tel No. . Installer's Name;Address,and Tel.No.,, Soda T Ts= g r ' r t:TyPe of Building: - W Dwelling No.of Bedrooms ��' V' f ! �Lo Size q fir. sq.ft. Garbage Grinder( ) Try Other ,._ Type of Building No.of Persons ~� Showers( ) Cafeteria( ) Other Fixtures :'e- Design Flow(min.required) �p �` gpd Design flow provided Plan Date' s ,r Number of sheets Revision Date Title " ' Size of Septic Tank, ��G, 4 TYpe of S.A.S. Description'of Soil t Nature of Re airs or Alterations Answer when applicable) ' } x P ( .- O //� Date last inspected: 6 Agreement: .4 The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in Z accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe ... Date Application Approved by n e Date 7' Application Disapproved by Date .1 for the following reasons Permit No. Date Issued zlv c�� a_��_. ----•- s THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(G)'� Upgraded( ) Abandoned( )by at �v e7 4'• o has been constructed in accordance 1i with the provisions ofTitle 5 and the for Disposal System Construction Permit No dated Installer /��� --�.,,_ Designer #bedrooms Approved design flo _4'�/, -7 gpd The issuance of this permit shall not be construed as a guarantee that the system UTI tion as designed e . Date 11) 1-7 Igo Inspector , 1 ---- ---- ----- ---- _.- --- =_-- -.---- No, '—n Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pste j Construction permit Permission is hereby granted to Construct( ) Repair(4,,1)- Upgrade( ). Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. z . Provided:Construction mu"t be c`mpleted within three years of the date of this perrchit. Date l !! W Approved 'own of,arnstb]e s OME y� R:hitory'Serv1C' - _ Richard V.Scali,,Interirn.Director f- • BARNSrABLEi ' f•:t Public I[eal`th Ahviso>n' - C> pTFD is Thomas:McKean,Director ' 200-Main,Street,•Ifyannis,"M 10260' lX Office:, 508=862-4644: Fax 508 790�6304 Installer&•Desis ner.Certification.Form Date;; .'16 C ' Sewa e P;ermit# 2.t�w-2q g Assessor' � rcr :Designef; h luiC Installer: Cj e �3� , Cf Address: �2 :Vtl, c :�./c/ Addressi t3 r Qn .0-7-.'Zt�La _ � =� was issued a peraiit.to.instalL'a (date) (installer) septic system at ? 776. ' t S- ;r�S S� based.on a.des gn dra:w by •` _. • (address)• - _ • dated .(designer) , I certify that the:septic system referenced:above was installed stibstantiall`:-accordir .t y go the:design which,:rrlay=include minor approved-changesysuch as lateral.re location of the distribution box and/ or'septic tank. Strip out:.(if rgqui.:red)., as inspected and-the;soils;' were found.satisfactory . I certify that the; septic system referenced above was installed with major`clianges (i.e:. greater than I0' lateral relocation of the SAS or any vertical relocation of any component; of the:septic-systein) but'in accordance with State &Local Reb latioixs Plan revi ion oT certifed as=built by designer to,fallow. :Strip`.out(if required)_was inspected and;tl e� ils, were found satisfactory. , I certify that the system:referenced"above was constricted m with the.>tenns- r of the 11A approval.;letters;(fvpl cable) (Installer's Signature). C►v►L 40.35109 RL isSE�� ' (Designers Signature), `(AfMxiX signe eze) PLEASE RETURN TO BARNSTABLE PUBLIC H,19 LTH DIVISION. CERTIIF'ICATE:, OF COMPLIANCE WILL. NOT BE :ISSUED UNTIL BOTHTHIS`-FORM 'AND AS- BUILT CARD ARE RECEIVED BY THE`BARNSTABLE-PUBLIC HEALTH'DIVISION. THANK YOU.:. Q ;Septic ,signer Cer-tification Form Rev 3 144 aloe Engineers note:This.certification.is limited to an as-built inspection.of sy5tem'components as installed.prior to,6ackfill.The engineer did.not supervise construction of the system.The installer:assumes responsibility for all materiais„workmanship;baekfilling;. to specified grades with proper compaction,and setting risers/covers as shown on the design,pian., p a r Rftl r 7 cb'-fd ,Mkt Itc t• ' ddi'E.s$:- i yam.._ " ' m`A � . ..i i�, araix&sine 4 �tt � a9ta`iiiir, tesespi �t,� tki ,'hlowt� � tft €taw k ;y is a naki[rn t r � 'kcaa� 1 zTttie�: W76r:�caf r e alis�ta� . c rtt tip eci 6 el t1 t��ott�afimn , _ jqF 1'h e. ,`-prig i c " p c5f tBt 1 tt .,T:tA,-teichh6lgg NP'13' [Otto . 1 ' aeziiaTi Ct ;ti� s� ttrnsit� ,tcfin�� 3?,, '_,. be 'piked+ tt `the ��r° �4!�$nii8lu t I i a Ve,,beea�.,p r�tr ded ith:k e.t ��, 5ys661 Initelead rt� 46 a5,s1► 1 i s ", p 1,ry � e „ r 6 h - 4 c• ,1� - fesor�s�km►tties tcs pc�v79:. � ": ,e1art� :31,Q.. '. rl c' lN A ' Wva14", t ial 11 ii re a kl�i � �`ta.; ��;c�w��d,���e�rr�n i�at����t�r�n��'t�ts����c� �-tt:►`.�t�y�tarc+�:�d_J�v�geu�s��rl by. _ w. < w ' '�' iet et r►�11 � L 't r f y r arra k�r� ��n�1 tt t d 1 t" tver n �e rrd s '° 6eA(a,k e-T-. i ilul, DepatlfwU r�t t l�e t'h A � pa knee rare to _ td �u� 17 csi keEb i4 l f��6 ! trca+?c i� l d fe l 1 1 AFL, 'ltjlurp .lasj t+stk.Cd,• itiEpG� ii ittid' 0031t, x inetb �t cr��uao �i try 1 t- ik "tl. aiie a - a d_ a v em tdti cri� rstR rwvnar carti walirtis r R. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................................OF...................................... SS'O©CY Applua#ion for Diapetial Works Tnnitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..----•-----•------.... ............................•---.......... 7—s •- �Location-Address or Lot No. Owner Address . ............. ryll < �?.. � 1� .....----------------------------------- Address � Install Address //�'/� Type of Building Size Lot...... _._Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder 1�&)- aOther—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*capacity.--G-Qgallons Length................ Width................ Diameter................ Depth..._ ......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--- ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.................. ft. Z Other Distribution box ( ) Dosing tank ( ) •.' Percolation Test Results Performed by.......................................................................... Date......................................... a ,.-I Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0+ •••••••--•••--•--------------••••-••--••••••--•--••••••••-••--••-••-•••••••............---•-••---••.......................................... ----------- •.... 0 Description of Soil........................................................................................................................................................................ x V .....••••••••••••••••--••••••----••••••.....---•••••-•••-•-•••-••-•--•-•••••-••••••----••------•----•••---•-•-••••-•-•--•._...------••-•-•-••-•-••-- -• -••• •-••••••• •••-• ••. V Nature of Repairs or tergti° —Answer when app ' blew_r............................ ....... ................................................... /ems?'/ Y ' C. 1,.0........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue the board of health. Signed _ ._ ..•-•----• ----• . ..•••.. �. Date Application Approved By•--•-•------- -- •••••. .......... -------• ---------------------------- Date Application Disapproved for the following reasons:_ . ..._...........5 .......... ....... ' ......•.....-----•------------------------------•----------------•-----......--•-••--•-•••-•---•••••----..._...._.........---------•-------------•--••••......--•-•------ 7----- Date PermitNo......................................................... Issued.-...................................................... Date -----------.------------ No. .:: . Fss . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF...............................I.,........................................................ Appliration for Diipuiittl Works Ton,atrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: X _r� /.i�4 1�-/,! _ a�1- .:-- ----------------------- ------ --------............--------- ,,. Address or Lot No. Owner r Address ; , ''C,k- -'......................... ................................................. ` ..... -1 Instal Address Type of Building U .. Size Lot.... /12 :I...Sq. feet Dwelling—No. of Bedrooms.......... Expansion Attic Garbage Grander A6 Other—Type of Building No. of persons............................ Showers — a g --}-----------------------•- P ( ) Cafeteria ( ) Otherfixtures .------..--•-•-••----•--•--•---•--••-•-..•-•----•-••-••.----•--••••--•---••-•-•-----•--•--•-•••••••----•---.....•--••••-••-•••.......................•- W Design Flow............................................gallons per person per day: Total daily flow..............................................gallons. WSeptic Tank—Liquid capacity/0'416.gallons �l Length..........:..... Width................ Diameter....::....___... De tlr.... .._....... Disposal Trench—No.. Width ::.� x p ...... Total Length.................... Total leaching area._ .-sq. ft. Seepage Pit No_________________`- Diameter......................Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results ,Performed bY=--•-•----•------•----•-••-•--••--••-.....--............................. Date..............................::....--- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---••----••••••••---••------•-•------•- ------------------------------------------•--••-----......--•••----•-••-••--•-•-•---•-----•--••----...---•--•---•-. 0 Description of Soil......................====.....................................................................................••......................................................... x W ....-•----•--••--•--••••---------•----••----••-----.....-•--••••-•----•--•--•----•---•.--...•-•--•.....••--•------•---•-----•-•------•---••--•-•-•-----......•-•-••••.................................. V Nature of Repairs or Alterations—Answer when app ' ___ble_ _______________________________ .___.........._...._................:........... , Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a-Certificate of Compliance has been iss .- the board of, jth. ned C �•- Si � g - Application Approved By:= -- �.- r= . .. '�..--------- # Date Date Application Disapproved for the following reasons:............. ........................ ...........................•----. ........ ......................................................................................... Date Permit No............ ---------•-•.............. .,Issued----------•-------=------..............------------•-- Date THE COMMONVI/EALTH OF MASSACHUSETTS BOARD OF HEALTH '. .............-rif.......C......OF..............„ ................................................... Trrtifiratr of w1implitanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by................. ....... V.,ek.-`7........................................................................................._ Installer at............................................................................................ ---------- --------------------------•---•---------------- --------- has been installed in accordance with the provisions of TIlLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. _Ct�_.� ® [ .......... dated-------------------------------------------•---- _ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 9 DATE. - �ay ....................... Inspector.... .....1/...•...------------------------------........-•-•---------•---•--•---. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH d ..... -.........oF.......... .. .... ........... . :............................. r No..�................... FEE/ ................ �nn�trnrtila�. �it Permission is hereby granted r�...... ........mq, {._� v c '.io.? to Construct ( ) or�Repair �)� an Individual Sewa a Disposal System , atNo............................................................................................................. Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ' -- - -- ------------------------------------- Board of Health DATE. ` t FORM 1255 A. M. SULKIN. INC.. BOSTON Commonwealth of Massachusetts o?,se- DOG S' . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f- >e .rY 2670 MAIN ST-ROUTE 6A-MAIN HOUSE Property Address . JAMES NORTON Owner Owner's Namea information is TABLE MA 02630 6/10/2020 . " required for every BARNS . _ page. Cityfrown State Zip Code Date of Inspection r.I 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 ti f A. Inspector Information \ filling out forms p �'� '�(pad on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return key. Company Name 350 Main St. 11 Company Address W Yarmouth / MA 02673 Cityrrown State Zip Code 508-775-2825 SI-14423 Telephone Number License Number B. Certification I certify that: I am a DEP approved system Inspector In full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function. and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by-the Local Approving Authority 4. ❑ Fails 7/1/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the'system has a design flow of 10,000 gpd or greater, the inspectorand the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 1 of 16 h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ rY 2670 MAIN ST-ROUTE 6A-MAIN HOUSE t Property Address JAMES NORTON Owner Owner's Name information is required for every BARNSTABLE MA 02630 6/10/2020 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 CONDITION 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): t5insp.doc•rev.7f28/2018 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form . . Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 2670 MAIN ST- ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name Information Is required for every BARNSTABLE MA 02630 6/10/2020 page. Cityrrown 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): I 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.712812018 Title 6 official Inspection.Form:Subsurface Sewage Disposal System•Page 3 of 18 cam. Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f a 2670 MAIN ST- ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name Information is required for every BARNSTABLE MA 02630 6/10/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 1.00 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r . 2670 MAIN ST- ROUTE 6A- MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name information is BARNSTABLE MA 02630 6/10/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to"All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box_above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %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 groundwater 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 6e 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 16,000 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 Arinking 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 t51nsp.doc•rev.7/28/2018 Title 6 Official Inspection form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 , r 2670 MAIN ST-ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name Information is required for every BARNSTABLE MA 02630 6/10/2020 page. City/Town 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 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)] t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form g Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 MAIN ST-ROUTE 6A- MAIN HOUSE F `J Property Address JAMES NORTON Owner Owner's Name Information Is required for every BARNSTABLE MA 02630 6/10/2020 , page. Cityfrown 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: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(include laundry system inspection [I Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): '19-202 GPD '18-153 GPD Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT Date t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts > Title 5 official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 MAIN ST- ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name information is required for every BARNSTABLE MA ' 02630 6/10/2020 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): canons 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: k Last date of occupancy/use: Date f Other(describe below): 3. Pumping Records: - Source of information: 2018 PER CUSTOMER Was system pumped as part of the inspection? Yes, ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? SITE GLASS MAINTENANCE Reason for pumping: 4 t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 MAIN ST-ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name information is required for every BARNSTABLE MA 02630 6/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No- 5. Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5lnsp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 `p 2670 MAIN ST-ROUTE 6A-MAIN HOUSE `� • Property Address JAMES NORTON Owner Owner's Name Information Is required for every BARNSTABLE MA 02630 6/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 18"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: 1000 GALLON Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 1, 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 How were dimensions determined? ESTIMATED 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 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN.TANK AT NORMAL OPERATING LEVEL. t5insp.doc rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts rA Title 5 Official Inspection Form YSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 MAIN ST- ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name information is BARNSTABLE MA 02630 6/10/2020 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 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): t 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 Commonwealth of Massachusetts L r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 2670 MAIN ST-ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name information is required for every BARNSTABLE MA 02630 6/10/2020 page. City/Town State Zip.Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: 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 EVEN 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 ..J Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 2670 MAIN ST- ROUTE 6A- MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name information is required for every BARNSTABLE MA 02630 6/10/2020 page. Cfty/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6X6 PIT ❑ leaching chambers. number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leachingfiields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t51nsp.doo•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 XN Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 MAIN ST-ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name Information Is required for every BARNSTABLE MA 02630 6/10/2020 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.): N 1-6X6 PIT FOUND WITH 18"OF LIQUID: NO EVIDENT HIGH STAINING. COVER IS AT GRADE r 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u .'r 2670 MAIN ST- ROUTE 6A- MAIN HOUSE Property Address JAMES NORTON - Owner Owner's Name information is required for every BARNSTABLE MA 02630 6/10/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont:) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form � a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 2670 MAIN ST- ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owners Name Informrequired tion is BARNSTABLE . MA 02630 6/10/2020 required for every 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 t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u r 2670 MAIN ST- ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owners Name information is required for every BARNSTABLE MA 02636 6/10/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water " ® Check cellar ® Shallow wells +11 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record 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 DOWN 12'WITH NO WATER ENCOUNTERED ` Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments 7, 2670 MAIN ST- ROUTE 6A-MAIN HOUSE Property Address JAMES NORTON Owner Owner's Name required for is every BARNSTABLE required for eve i MA 02630 6/10/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary:, 1, 2, 3, or 5 completed as appropriate 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 t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 10 4 ; g 4-�) ' 6J f . tNE tom, Town of Barnstable Barnstable Inspectional Services ' edcaC j anwv raBm MASS. Public Health Division arFg MPS a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9576 March 12, 2019 NORTON, JAMES & ROBBIE 1069 WEST BROAD STREET#756 FALLS CHURCH, VA 22046 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 2670 Main Street, Barnstable, MA Cottage, was inspected on 02/22/2019 by Nicholas Geneseo, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Single Cesspool. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE RD OF HEALTH L an, R. ., C Agent of the Board.of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\2670 Main Street Cottage Barnstable MA.doc r , f.f Town of Barnstable • s�xsr�s�. 9. Regulatory Services Department - _--�- -�----Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) ' An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO 2 YEAR DEADLINE CRITERIA Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments :t> ^M 2670 Main Street,Cottage - Property Address Owner James Norton t information is required for every Owner's Name page. Barnstable MA . 02630 February 22,2019 � h City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in anyway. Please see completeness checklist at the end of the form. A. Inspector Information 1. Inspector: Nicholas Geneseo Name of Inspector Wind River Environmental Company Name 46 Lizotte Drive Suite 1000 Company Address Marlborough MA 01752 City/Town State Zip Code 973-830-6126 S113988 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information , reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: ❑ Passes ❑ Conditionally Passes ❑ Needs Further Evaluation by the Local Approving Authority Q Fails February 22,2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System a Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street, Cottage Property Address Owner ,lames Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 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: 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) t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street, Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 Cityfrown 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: t5ins.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 a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street, Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 CitylTown State Zip Code Date of Inspection C. Inspection summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private- water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ [J1 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Q Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street,Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 Cityfrown State Zip Code Date of Inspection C. Inspection summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ [Q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ❑ Q Liquid depth in cesspool is less than 6"below invert or available volume is less than Yz day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Q Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 2 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000gpd-10,000gpd. Q ❑ 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 Il of a public water supply well t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street, Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 62630 February 22,2019 City/Town 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"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 ❑ Q Pumping information was provided by the owner,occupant,or Board of Health ❑ Q Were any of the system components pumped out in the previous two weeks? ❑ Q Has the system received normal flows in the previous two week period? ❑ Q Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ N/A Q Were as built plans of the system obtained and examined?(If they were not available note as N/A) Q ❑ Was the facility or dwelling inspected for signs of sewage back up? Q ❑ Was the site inspected for signs of break out? Q ❑ Were all system components,excluding the SAS, located on site? Q ❑ 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? Q ❑ 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: Z ❑ Existing information. For example,a plan at the Board of Health. Q ❑ 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)] t5ins.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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street, Cottage Property Address Owner James Norton information is Owner's Name required for every page. Barnstable MA 02630 February 22,2019 City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): N/A Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203(for example; 110 gpd x#of bedrooms): 110 Description: Cottage to a Cesspool Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes 0 No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes Q No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes 0 No Water meter.readings, if available(last 2 years usage(gpd)): Unknown Detail: Unknown due to vacancy. . Sump pump? ❑ Yes 0 No Last date of occupancy: Unknown Date t5ins.doc •rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street, Cottage .Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 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): General Information 3. Pumping Records: Source of information: Wind River Environmental Was system pumped as part of the inspection? Q Yes ❑ No If yes,volume pumped: 20 gallons How was quantity pumped determined? Pump Truck Sight Glass Reason for pumping: Cesspool required to be pumped at time of inspection t5ins.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street,Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank,distribution box, soil absorption system Q 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 ofinformation: unknown field stone cesspool Were sewage odors detected when arriving at the site? ❑ Yes Q No 5. Building Sewer(locate on site plan): , Depth below grade: 1 feet Material of construction: 0 cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints,venting,evidence of leakage,etc.): The plumbing is under the cottage in a crawl space and shows no signs of leakage.The sewer line appears to have good pitch. t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street,Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) + 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass. ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street,Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 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 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 t5ins.doc rev.7/26/2018 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 11 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o 2670 Main Street,Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 CitylTown 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 NSA 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.): N/A t5ins.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 2670 Main Street, Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): *If pumps or alarms are not in working order,system is a conditional pass. 11. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Single Cesspool Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street, Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 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.): 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 Depth-top of liquid to inlet invert 6" Depth of solids layer 0" Depth of scum layer 2" Dimensions of cesspool 6'X 7' Materials of construction Field Stone Indication of groundwater inflow ❑ Yes 0 No Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Large,overgrown pricker bushes are over the cesspool.There are no signs of hydraulic failure or groundwater intrusion. Per town code,cessaools are an automatic failure. t5ins.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 2670 Main Street, Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): t5ins.doc rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System 9 Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street, Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 Cityrrown 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: Q hand-sketch in the area below ❑ drawing attached separately g f! /�/� ✓uL'.- at� is� oS C - Y n 4' E p' 3 y fil - r t G 5 � 't. 1 G pNl S t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street,Cottage Property Address Owner James Norton information is Owner's Name required for every page. Barnstable MA 02630 February 22,2019 City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Q Check Slope Q Surface water Q Check cellar Q Shallow wells Estimated depth to high ground water: To Be Determined when designing new system. 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 Q 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: i You must describe how you established the high ground water elevation: Groundwater to be determined at the time of system upgrade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 18 f r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2670 Main Street, Cottage Property Address Owner James Norton information is required for every Owner's Name page. Barnstable MA 02630 February 22,2019 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Q A. Inspection information: Complete all fields in this section. Q B. Certification:Signed&Dated and 1,2,3, or checked Q C. Inspection Summary: 1,2,3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed Q D.System Information: For 8:Tight/Holding Tank-Pumping contract attached For 15:Sketch of Sewage Disposal System drawn on pg. 16 or attached t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 18 i �zT Town of Barnstable Barnstable ky Regulatory Services Department I".ca�.I + 1ARNSfAB1.E. 'HAS � Public Health Division m 1639. ♦0 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 " Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012 1010 0000 2848 2237 July 20, 2017 ; NORTON, JAMES R PO BOX 60 CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 2670 Main Street (Rt 6A), Barnstable, MA was inspected on 06/22/17 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00)due to the following: • Leaching pit or cesspool with high liquid level,<12" below inlet (per Town Code 360-9.1) and leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. x Failure to repair/replace the septic system within the deadline.period will result in future enforcement action. 4 PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO ' Agent of the Board'of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\2670 Main Street Bamstable.doc is Mill ■ Complete items 1,2,and 3. Mig" re ■ Print your name and address on the reverse X — ❑Agent so-that we can return the card to you.. 13«' `'q' s Attach this card to the back of the mailpiece, B.R efyed by(Printed Name)p ID. Date of Deir.eq I or on the front if space permits. `5�+�"p 0 'Fri 1. Article Addressed to; D.is delivery ad ifferent from item]? L Y-.4 If YES, ndlWery ress below: ❑No_ I� /I/or Ta S ��° IVF� - ��l V ?0 8 DEC b3. Service y �oti�ti1 III�III�I ICI I�IIIIIII II II Iflllll III flllll IIII ❑Adult dultSgnatureRestrictedDelivery pR gistered Mail Restricted V rtilled WHO livery (�Ce 9590 9402 1934 6123 0976 23 rtified Mail Restricted Delivery �Retum Receipt for 4 q Collect on Delivery / Merchandise 2._Article-Nu mber[Transfer from servire/ahciit O'C.ollect on_Delivery Restricted Delivery O Signature CoMrmationTM O Signature Confirmation 7 012 1010 0 0 0 0 2 8 4 8 2 2 3 7 �i:ReeMcted De„very Restricted Delivery PS Form 3811,JUIy 2015 PSN 7530-021000-9053 ! Domestic Return Receipt USPS TRACKING# . Postage&Fees Paid USPS Permit No.G-10 I 9590 9402 1934 6123 0976 23 NO United States •Sender:Please print your name,address,and ZIP+4®in this box* Postal Service Town of Barnstable I F Health Division 200 Main Street Hyannis, MA 02601 i .11i F_�ti.# liil E''F;i;tf : F F °;i f F 1;=j- it . = Fj FF 1f1; l � l; s Fllll tt •�;hill ;rjd� F I � �.O a � m��n s�-� �� I ��� y ' D .. • '. ru , nu ''1 I !V Postage $ rti l� '� �,• Certifled Fee �,��� O V. Return Receipt Fee P ?!� p M (Endorsement Required) Here Restricted Delivery Fee O (Endorsement Required) r=1 O Total Postage&Fees rR fU Sent To/�/ //.f J) r9 (_'-_O!_7 X --I w- --------------------- Street, t.No.; r or PO Box No. D 3- ------- Certified Mail Provides: a A mailing receipt c A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: ! o Certified Mail may ONLY be combined with First-Class Maile or Priority Mail& e Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the, fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,pplease present the arti- cle at the post office'for postmarking.•.If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. t • IMPORTANT-Save this receipt and present it when making an inquiry. PS Form 3800;August 2006(Reverse)PSN 7530-02-000-9047 1 • Town of Barnstable MASS&• �+xxsrasr.E, Regulatory Services Department • �fb MK{� Public Health Division 200 Main Street,Hyannis MA•02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TOREPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15,000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground 4 ❑Pumping more than 4 times during•the last,year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLM CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). . TWO (2)YEAR DEADLINE CRITERIA • • q m o0 . - • ❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to.H-10 components, etc) •• Leaching pit or cesspool with high liquid level, <12"below inlet (per Town Code § 60-9.1) Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Cl Repair deadline: WSEPTIMDEADLINES TO REPAIR FAILED SYSTEMS.doc a 58-008 .; Commonwealth of Massachusetts - Jitle 5 Official Inspection -Form _ Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments M 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every 'West Barnstable MA 02668 6-22-17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information .4trng out forms , on l the computer, #�;' OFuse only the tab1. Inspector:key to move your cursor-do notEJames D.Sears use the return r' key. Name of Inspector Capewide Enterprises s�j:• �?fitf ..Ica —V Company Name qe 5 C.I N Sp� 153 Commercial Street '���►n,,,,,,,,,,,,uv``�� Company Address Mashpee MA 02649 City/Town State Zip Code 598 477-8877 S1623 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system_ inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority —/ 6-26-17 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. (w VS t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Asposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M °v 2670 Main Street(Rt 6A) Property Address James Norton Owner Owners Name information is required for every West Barnstable MA 02668 6-22-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304-exist. Any failure criteria not evaluated are indicated below. Comments: Failed system - leaching. The system is a 1000 Gal. Tank D Box and pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not .determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier; if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system.component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® E'l Liquid depth in GUAM is less than 6" below invert or available volume is less than '/2 day flow Pi 7— t5ins.doc•rev.6/16 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 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 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 must serve a facility with a design flow of 10,000 gpd to 15,000 gpd For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—.IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 page. City/Town 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): NA Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts N w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2015-30,000Gals g ( y 9 (gp )�' 2016-28,000Gais Detail: Sump pump? ❑ Yes ® No Last date of occupancy: PresentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.)-. Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 . page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information, Pumping Records: Source of information: NA 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1984 Permit # 84 - 1016 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 8" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) IIf tank.is metal, list age: years f Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No N Dimensions: 1000 Gal. Precast H-10 Sludge depth: 211 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 page. Citylrown 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 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank and cover at 8" below grade. Outlet tee. No sign 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 of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No ' Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts. w v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every west Barnstable MA 02668 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Note: D Box on asbuilt. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit w/ 1'stone. Pit full , Not leaching. Need to replace leaching. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official 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 M 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every west Barnstable MA 02668 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r 4 w - Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is required for every West Barnstable MA 02668 6-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately `} 03 -3 � Q - M t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 L4'C A T I O N 20 S E W A C E PERMIT qQ. IRSTA LLEJR'S NA FOE. A ADDRESS ! _ LJ 1 IIIUILDER// OR OWNER DATE PERMIT ISSUED / DATE COMPLIANCE ISSUED T / Ho056� iTiok)i l �7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is West Barnstable MA 02668 6-22=17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N° Estimated depth to igh 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: Abutting property no G.W. seen. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2670 Main Street(Rt 6A) Property Address James Norton Owner Owner's Name information is West Barnstable MA 02668 6-22-17 required for every 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 System s)'com pleted ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17- �Yrti Town of Barnstable Inspectional Services Department &1RN$T'ABLE, 9. ,�� Public Health Division rf0" A 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 1432 February 21, 2020 2670 MAIN STREET LLC 1069 WEST BROAD STREET#756 FALLS CHURCH, VA 22046 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 2670 Main Street (Rt 6A), Barnstable, MA was inspected on 06/22/17 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high,liquid level, <12" below inlet(per Town Code 360-9.1) and leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You were ordered to repair or replace the septic system within two (2)years from the date you receive notification letter dated July 20, 2017. The septic system was inspected again on 11/16/2018 by Nicholas Geneseo, certified Title V Septic Inspector for the State of Massachusetts. The septic system will have to be inspected again by a different private inspector at least six (6) months after the date of the-'passing inspection report. See attached policy. If you have any questions, contact Public Health Director, Thomas McKean, at 508-862-4640. After a third septic inspection has been completed and passes, please contact Sharon Crocker at 508-862-4644, to schedule a hearing before the Board of Health. Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\2670 Main Street Barnstable Re inspection Notice.doc OFF t Barnstable Town -of Barnstable " 1A MS . , MASS. ` Board of Health 9 A •6g9• `rfc 200 Main Street, Hyannis MA 02601 Zoos Office: 508-8624644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi Public and Environmental Health Program February 15,2012 Policies,Procedures,and Guidelines Septic Systems Documented as Failing to Protect Public Health and Safety and the Environment by a DEP Approved System Inspector Later Documented to have a Passed Inspection for the Same System Conducted by a DEP Approved System Inspector#2012-01 (Section 15.305 of the State Environmental Code, reads as follows 'if a system is failing to protect public health, safety, welfare, or . the environment as set forth in 310 CMR 15.303(1)or 15.304(1), the owner or operator shall upgrade the system within two years of discovery unless:(a)a shorter period of time is set by the local Approving Authority or the Department based upon the existence of an imminent health hazard;or(b)the continued use of the system is permitted by the local Approving Authority in accordance with the provisions of an enforceable schedule for upgrade. The Town of Barnstable Board of Health will consider permitting the continued use of a septic system which has been documented to "fail to protect public health, safety, and the environment but later documented to "pass" an inspection by an approved System Inspector conducted in accordance with 310 CMR 15.302 and local Health Regulations. To consider such an extension, the applicant is required to provide the Board two passing inspection reports conducted by two,independent or separate DEP certified inspectors. The two independent passing inspections shall be conducted at least six months to one year apart. The following procedure shall be followed for consideration by the Board to grant an extension or to overturn a failed septic system inspection report: 1. The applicant shall submit four copies of the failed and passed inspection reports to the Health Division Office (200 Main Street Hyannis Ma) at least thirty days before the established deadline to repair the failed system. These documents will be forwarded to the Board members for review prior to and during the next regularly scheduled public meeting. [NOTE: At properties used for seasonal use, inspections should be conducted during periods of heavy usage] 2. During the public meeting, the Board will determine whether or not the application would qualify for an extension. The Board will also determine whether or not to require or recommend another septic system inspection which shall be conducted six to twelve months after the first passing inspection. The Board may require the additional inspection(s)to be conducted during a specific time period(i.e.during summer months)at seasonal properties. 3. Immediately after the third inspection is conducted(six to twelve months later)the applicant shall provide the Health Division four copies of the third septic system inspection report, regardless of whether it's a passed or failed result. The ;Health Division will forward the documents to the Board members for review prior to and during the next scheduled public Board of Health meeting. At that meeting, the Board will determine whether or not the application would qualify for any additional extensions a nd/or deter mine whether or not two passing inspection reports would overturn the failing inspection originally submitted. Wayne Miller,M.D. Junichi,Sawayanagi Paul Canniff,DMD C:\Users\trippv\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Out]ook\W46U9S67\FailedSepticSystemsWithPassingReports.doc A(a Commonwealth of Massachusetts Title 5 Official Inspection Form Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' < � 2670 Main Street Property Address rQ James Norton _ Owner Owner's Name information is r„ required for every Barnstable MA 02630 11/16/2018 page. City/Town State Zip Code Date of Inspection ..:e Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information c�/ 13 50� filling out forms on the computer, use only the tab Nicholas Geneseo key to move your Name of Inspector cursor-do not. Wind River Environmental use the return Company Name key. 46 Lizotte Drive Company Address Marlborough MA _ 01752 City/Town State Zip Code -�� (973) 830-6126 SI 13988 Telephone Number License Number z B. Certification i certify that: I am a DEP`approved system inspector In full compliance with Section 15.340 of Title 5 (31.0 CUR 15.000); l have personally inspected the sewage disposal system at the property address listed above;the information reported below=is true;;accurate and.coinplete 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:-s em: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by`the Local Approving.Authority 4. ❑ Fails a.ter I/ spec'ws ignaiure Date The system inspector shall submit a copy of this inspection report to.the Approving Authority(Board of Health&DEP)within 30 days of completing.this inspection. If the system has a design flow of 101000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DER The or form should•be sent to the system owner and copies sent to the buyer;if applicable; and the,approving authority. Please pots: 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.71261MIa Title 5'0fficia1 Ins00on Form:Subsurface Sewage Disposal System:-Paget of 18 Commonwealth of Massachusetts �x Title 5 Official _Inspection Form Ir �I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2670 Main Street V� Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 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: The system is working as designed at this time. Recommend pumping annually. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts �n Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 page. CityFrown 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 ,qP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA' 02630 11/16/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.- The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". t 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 �r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l u 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No , ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s): Number of times pumped: ❑ E 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 1 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.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 2670 Main Street u- Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 page. CityTTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to an question in Section C.5 the system is considered a significant Y Y Y q Y 9 threat, or answered "yes."to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) I ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspecfiort Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a �� 2670 Main Street V Property Address James Norton Owner Owner's Name information is Barnstable MA 02630 11/16/2018 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 CR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD M Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last'2 ears usage d Unavailable 9 ( Y 9 (gp ))� Detail: Unavailable Sump pump? ❑ Yes ❑ No Last date of occupancy: Current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form 'T r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2670 Main Street V Property Address . James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 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: Wind River Environmental -See attached record. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,000 gallons How was quantity pumped determined? The quantity was measured by the pump truck. Reason for pumping: To check the structural integrity of the septic tank. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 l Work Order# 0217067770 Cust# 13 0 015 0 Customer Since: 2 0 0 5 Tax: 6 . 2 5 0 0 0 Job Comments Tech Comments 11/16/2018 WRE to pull plans - Title 5 - 1000 'gals in the Oct 19&#xOD; backyard, + Cottage tank will be sending water usage/consent 20184205251. form cc on file (dg) plans in account JL 6/2/05 Title 5 inspoection is completed. System Owner System Location James Norton Primary Home 2670 Main Street 2670 Main Street Barnstable, MA 02630 Barnstable, MA 02630 (202) 360-3064 Norton James (202) 360-3604 Service Date: FR1 11/16/2018 o9:oo Am Frequency: Call to Confirm: Service Type: standard Previous Service: 10/16/2018 Approx. Gals: 0 CCLS: ; ,•, Location Details: Depth Below Grade: Custom Clean: y Cust Home: YES Filter:,.-, rv,, Township: �1nspectton/�T5: County Barnstable BtitldUp "NN Qescr�pt�orl� �VF£;�' , . a� Q .. lnt ie , Ext�Pt Inspection Title 5 W 1 0At} $ 36510000 $ 365�00 Inspection (Labor/Exposure Fees)perk hr x 00 $ 1849990s $ ,�0 00 z € Fuel / Energy Recovery 1��0tY $ 9225�92 jW$ '2 2 Inspection .Title 5 BOHVFees,, � PNOWN, , �r1..,005 .., .25;.-.0,00.0." $ ,., 2:5.B0fl .. . .sum Pumping 1501 - 2000 1.00 $ 473.7200 $ 473.72 Environmental Compliance Residential �1 00 $ 3:0000 $ 3W OQ w.,w. 3±.!E5: ,.7/.i.- zom.t R5..«. 1 .... .. .... ::.:d ��. •` S ORRV d- We suggest these 3 keys steps to keep your system healthy: �§ubtota[.•.$• 958.98 Tax $ 0.00 ' Regular servicing • Use CCLS bacteria additive Total $ 958.98 . Use a filter Disposal Site: Disposal Volume: Payment Detail: Waste Code : 0.0000 Amex xxxxxxxxxx1002 04/2021 Sales Rep : NE_Repairs Installs CSR : Tara Villegas Due on Receipt Truck : Technician : Nicholas Geneseo On Site : o8:51 AM P 0 Number Tech Notes : System Operating Fine. Normal water level. Light top solids. Light bottom sludge. Both baffles are intact. Main line Clear. No filter is present on the tank; current tank can be outfitted with a filter. Cover(s) secured. Title 5 Customer not on site is a pass, tank is at operating level with tees in place. Tank appear to be in good condition and box is water tight . Leach pit has 4' of available space and X no signs of hydraulic failure at this time. 2nd system to be inspected when do locates tank. NG. Customer Signature lam"" ENVIRONMENTAL Remit payment to 46 Lizotte Dr Suite 1000,Marlborough,MA 01752 Commonwealth of Massachusetts Title 5 Official Inspection Form ±= I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 2670 Main Street V Property Address James Norton Owner Owner's Name information is required,for every Barnstable MA 02630 11/16/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5'feet Material of construction: ❑ cast iron -®40 PVC ❑ other(explain): Distance from private water supply well or suction Fine: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Unable to gain access to see plumbing. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I i c Commonwealth of Massachusetts 1= Title 5 Official Inspection Form ?= I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 2670 Main Street Property Address James Norton Owner Owner's Name information is Barnstable MA 02630 11/16/2018 required for every - - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8' x 5' x 4' Sludge depth: 5„ Distance from top of sludge to bottom of outlet tee or baffle 29" 011 Scum thickness Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank appears to be in good structural condition. The tees are intact and the liquid level is normal. Recommend pumping annually. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 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 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 Commonwealth of Massachusetts Title 5 Official Inspection Form IR i, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments u � 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: 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.): The distribution box is 2.5' below grade with one outlet taking flow. The box is watertight and level. There is minimal solid carryover present in the box and no leakage at this time. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r Commonwealth of Massachusetts in Title 5 Official Inspection Form i, i Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on'site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 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 �x Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form'- Not for Voluntary Assessments u 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 page. Citylfown 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.): The leach pit has 4' of space between the inlet pipe and the liquid level. There is no high staining on the walls and no sign of hydraulic failure at this time The leach pit cover is on the surface. 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 �= 1` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 page. CitylTown 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 Commonwealth of Massachusetts w _ p Title 5 Official Inspection Form f r Subsurface`Sewage Disposal System Form -Not for Voluntary Assessments 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 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 17 V 3.` f y 3 a 30 --------------- d :3 Dirt Vf- w t5insp.doc-rev.712612018. Ti*5 Official Inspection Form:Substeace Sewage Disposal System-Page 16 of 18 t , Commonwealth of Massachusetts �x Title 5 Official Inspection Form' III Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments -:�// 2670 Main Street Property Address James Norton Owner Owner's Name information is required for every Barnstable MA 02630 11/16/2018 page. City/Town 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 auger used to-11'with no signs of groundwater. 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 i Commonwealth of Massachusetts �x Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 2670 Main Street V� Property Address James Norton Owner Owner's Name information is Barnstable MA 02630 1.1/16/2018 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 191 _ SubsurfaceSewage Disposal System Form - Not for Voluntary Assessments 2670 Main Street --- ---- --------- - ProPerty Address James Norton -------- Owner Owner's Name information is Barnstable MA 02630 11/16/2018 required.for every ------ --- -- — 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 - 17uG� I 3 - Q.y, 3 a o � DIf� w t5insp.doc•rev.7/26/2018 Ttde 5 Official Inspection Fotm:Subsurface Sewage Disposal System-Page 16 of 18 FIL COPY COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS / R DEPARTMENT OF ENVIRONMENTAL PROTECTION y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2670 Main Street Barnstable,MA.02630 Owner's Name: Jim Norton Owner's Address: Date of Inspection: 06/02/2005 Name of Inspector:(please print) Brad J White c�a Company Name:Windriver Enviromental f;` c:) Mailing Address: 107 N.Main Street CD 7 Carver,MA'02330 Telephone Number: (508)-866-2576 q cn CERTIFICATION STATEMENT co rn I certify that I have personally inspected the sewage disposal system at this address and that the info tion 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: X Passes } Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: e: 06/02/2005 The system inspector shall submit a copy of Zsinspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments System Passes. ****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 s conditions of use. i 6/15/2000 page 1 Title 5 Inspection Form r � Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION (continued) , Property Address: 2670 Main Street Barnstable,MA.02630 Owner: Jim Norton Date of Inspection: 06/02/2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 passes.Recommend regular service. (Groundwater info determined on 12/13/2004 dated for that day of inspection) 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: r, 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' a" ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2670 Main Street Barnstable,MA.02630 Owner: Jim Norton Date of Inspection: 06/02/2005 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 15303(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: Title G 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2670 Main Street Barnstable,MA.02630 Owner: Jim Norton Date of Inspection: 06/02/2005 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''/z day flow X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(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. XX 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 t 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 1>, , gni P� Y 15.304.The system owner should contact the appropriate regional office of the Department. T;t1a G rncnonfinn un—4/1;/,)nnn Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2670 Main Street Barnstable,MA.02630 Owner: Jim Norton Date of Inspection: 06/02/2005 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)] f 7 5 T41a 1;Tnc"."nn T'inr 411 VINW) Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2670 Main Street Barnstable,MA.02630 Owner: Jim Norton Date of Inspection: 06/02/2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_ Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330gpd _ Number of current residents: 2 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):Yes Seasonal use:(yes or no):No Water meter readings,if available(last 2 years usage(gpd)): 175gpd Sump pump(yes or no):NO Last date of occupancy: Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped after Inspection Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped: 1,000 gallons- How was quantity pumped determined?Sight tube on truck Reason for pumping:. check tanks structural integrity TYPE OF SYSTEM Septic tank,distribution box,soil absorption system . Single cesspool Overflow cesspool _Privy No 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: I ,System was installed approx 1984 per as built plan Were sewage odors detected when arriving at the site(yes or no): NO Titla G Tnenorfinn Form(,/1 VIAAA t Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2670 Main Street Barnstable,MA.02630 Owner: Jim Norton Date of Inspection: 06/02/2005 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line:N/A Comments(on condition of joints,venting,evidence of leakage,etc.):Building sewer,is in good conditon. SEPTIC TANK: X (locate on site plan) Depth below grade:8" 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: 8' x 5'-8" x 4'-8" Sludge depth:2" .Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness:2%3" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined:Measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): tees in good condition.Tank is structurally sound.No evidence of leakage in or out. GREASE TRAP:_(locate on site plan) L _ 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.): 7 Title C Tncnnnfinn Fnr.,,4/1Vnnnn I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2670 Main Street Barnstable,MA.02630 Owner: Jim Norton Date of Inspection: 06/02/2005 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):, Date of last pumping: 1 Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)(30"below grade) 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.):Distribution box is level and distributing evenly.No evidence of solids 1. carryover.No evidence of leakage in or out of the box. i PUMP CHAMBER: (locate on site plan) } Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):.. - Title.G T,nenantin»Fnrm//1 C17nnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2670 Main Street Barnstable,MA.02630 Owner: Jim Norton Date of Inspection: 06/02/2005 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,excavation not required) If SAS not located explain why: Type X_leaching pits,number: 1 @ 6' x 8' ( 2'-1"from pipe to ponding) _ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: _leaching fields,number,dimensions: _overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Soil is dry.No evidence of hydraulic failure.Vegetation is normal.No ponding on the surface. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions Depth.of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Tifln G Tncnnrtinn Fnrm r,11,;rmnn i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2670 Main Street ".`Barnstable,MA.02630 Owner:.Jim Norton`1 Date of yInsp++ection:06/02/2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Piovide a'sketch of the sewage disposal system including ties to at least two permanent reference landmarks or 1.benchmarkit Locate all wells withhij}n• 100 feet.Locate where public wat r supply enters the building. �'1'l fri2.{ %Lr�, tyt.' r..a{ 'yr` .. a a. ..,1{ - . .. `�O t•.. IY 0 �2 3q, � Tit1n C'Ttierantinn.Tinrni 10 ful rl,)A n 1 -99 --EXISTING CONTOUR ' 1161, PROPOSED S.A.S. x 100.98 EXISTING SPOT GRADE Fj 0 100 PROPOSED CONTOUR � ' / / 8 ROWS OF 10 HI-CAPACITY � \ `+\.36 83�3. H-20 INFILTRATOR .UNITS W EXISTING WATER SERVICE 11 ""a] +8 84 I G EXISTING GAS SERVICE \ ' BG19 _ - H. W.-OVERHEAD WIRES q� I r +9b.65 TEST PIT BENCHMARK. f-�Inckle l � \ \ 1 ^\ �• � • � ,2,80.05 LEGEND a � ;'," \/ / I l \ \ 1 1 1\ ' o� 7 2670 Main Street Pond I \ \ I I �. � � ' ,r �it �otn' / ! / CON�/ETIOt�{ALLYIZEJRVAL S.A. +.99.94 t ! J { ORJ ILLUSTTAIO� PER APP �ETTr r (]f15 x 86', EF ECTIV AR =220 SF N \ i PARC L ID:I 258-008 ► .. -'.f '~ �t LOCUS. MAP / 77.99 I I INSPIECTIO� PORTQi I \ I (I l8 I 1 , \ MANI OLDED VENT I GENERAL NOTES: - , CONS W/OWNER FOR VENT LOCAT�ON I I 1. ALL'CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL , XISTING EACH PIT BOARD OF HEALTH AND THE DESIGN ENGINEER.BE PU�PED, FILLED I �O_ 0 2•,ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS WITH SAND & ABANDON D I OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: EX/S lNG SEPTIC TANK -310 CMR 15.405(1)(b): O \+ 1�1LI� I `t 1) A 2' variance to the 3' maximum cover requirement, for 5' of 7e.zs / / ^ `i l TOP QF TANK, EL 98.39 _ x a.6a I V �/ I max. cover. S.A.S. shall be H-20 and vented. / / T rl 1 I I INV.(0 T)=97.06f / cp / t +��?� ' I 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFiLLED PRIOR / ,,'' 'I / TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE / ! / oo \ i-4-+j\ ` I` I I DESIGN ENGINEER. +97.41 �Q 7.60 Fi I irt�ll /h 4.. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING O LL1 11�JI FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 1 T TTT� / / P-1 > 1 f63 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. �8 a>urr wa�r� � r�+I 7l ,, „•,,;.>. %m6s7 - p0, +Qo.z7 CB 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF / P-2 '1 :§'I8 ./) �' 108 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF '7794.1 / 10141 / HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. / +88.67 %104.57 / % 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. +90.21 I OIJOV 106.65 C+e2.44 83.86 +86.22 o �`' ^ ,•: •"3 T/O 8. THERE ARE-NO WELLS WITHIN 100' OF THE PROPOSED S.A.S. r \ / 94.36 �C ` 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS �V r ',. 14 \ PROPOSED SEPT TANK I �' .Ur , 105.I5 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE EC \ I EX/ST/NG DIRECTED BY .THE APPROVING AUTHORITIES. C 89.89 951`3 . \ \ 10. IT SHALL .BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY �{ X91f (12670) �� THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING / CONSTRUCTION. 102.29 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS ..'•A6'.tT". �(` IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND SPIKE184, W.' 4 �F�� Y REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). VE +• P 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE o PETER T. �, ��� 100.35 INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. BH TTAGE '.'ORI�IEWAY ;. �4 CO 9�•< gyp° P�McENTEE -' 7.• 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND CD -, T. .F.'= S.bf 9532,t „',;: pl•.;: 00.3 OF CIVIL EXISTING CESSPOOL IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. "' 'c No. 35109 TO BE PUMPED, FILLED Q WITH SAND & ABANDONED / �R ,�� 95.61 �9488' 9 9:::,;.- r o� PROPOSED SEPTIC SYSTEM UPGRADE PLAN 93.76 '11�7 2670 MAIN STREET, BARNSTABLE, MA 93.40 "...94.18 / P��. 97.78 p �0D� Prepared for: Cape Cod Septic Services, 350 Main St, W. Yarmouth, MA 02673 OWNER OF RECORD Engineering by: SCALE DRAWN JOB: N0. 2670 MAIN STREET LLC Engineering Works, Inc. 1"=40' P.T.M. 211-20 1069 WEST BROAD STREET #756 �z FALLS CHURCH, VA 22046 I 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. 96.52 (508) 477-5313 8/28/20 P.T.M. 1 of- 2 NOTE: TO PREVENT BREAKOUT, FINAL GRADE SHALL NOT BE AT, OR BELOW, EL.=89.3 EXISTING FOR A DISTANCE OF 15' FROM THE EDGE HOUSE SEPTIC TANK PROPOSED D-BOX OF THE PROPOSED S.A.S. (( 2670) INSTALL RISERS & COVERS OVER INLET AND SET TO 6" OF FINISH GRADE. INSTALL WATERTIGHT RISER & PROPOSED S.A.S. COVER SET TO 6" OF GRADE INSTALL INSPECTION PORT OVER ONE ROW(MIN.) PATIO VARIES F.G. EL.=91.0 to 94.3t CHARCOAL PATIO VARIES F.G. EL.=92.5t(COTTAGE) F.G. EL.=93.Of VENT CORNER COTTAG e F.G. EL.=100.0t(HOUSE) CONNECT LMAINTAIN/2%. GRADE MIN. OVER S.A.S. ALL ROWS SLOG. BLDG. CORNER CORNER L 62' L = 13' (COTTAGE) INSPECTION S=1% (MIN.) L = 72' (HOUSE) L = 13' PORT 4"SCH40 PVC @4"SCH40(PVC) @4"SCH 0(PVC) 6" LLL10^I CORN E DECK COTTAGE 14" s" 7INVER O -'-moo INV.=90.25 48" LIQUID LEVEL NHOUSE ADD INV.=89.17 = 8 ROWS OF 10 UNITS AT 6.25'/UNIT = 62.5' GAS BAFFLEPROPOSED INV. 8 EXISTING COTTAGED-BOS INV.= . o INV.=90.00 H-20 SOIL ABSORPTION SYSTEM (PROFILE) �' d PROPOSED SEPTIC TAN (COTTAGE) HOUSE INSTALL EXISTING SEPTIC TAN (HOUSE) INV.=97.06 INLET TEE ESTABLISH VEGETATIVE COVER 0%K . BACKFILL WITH CLEAN NATIVE OR O COTTAGE: PERC SAND TO TOP OF CHAMBERS ���PO^ CONNECT TO EXISTING SEWER INV.=92.6f VERIFY BREAKOUT=TOP OQO TOP ELEV.= 89.33 Q INV.- 88.92 NOTES: TT -BOTTOM ELEV. 88.00 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE 4' MIN. SEPARATION 2.83' INVERTS, PRIOR TO INSTALLATION. TO GROUNDWATER 2) SEPTIC TANK AND D-BOX SHALL BE SET LEVEL AND TRUE 4' (MIN.) OF NATURALLY EFFECTIVE WIDTH=22.6' LAYOUT TO GRADE ON A MECHANICALLY COMPACTED 6" CRUSHED OCCURRING PERVIOUS SOILS SUITABLE SOILS S.A.S. STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). NO G.W., EL=79.5 3) INSTALL INLET & OUTLET TEES AS REQUIRED. USE 8 ROWS OF 10-HIGH CAPACITY H-20 INFILTRATOR UNITS 4) CONTRACTOR SHALL INSTALL AN APPROVED GAS WITH NO SEPARATION BETWEEN EACH ROW & NO STONE 0 0 0 0 0 0 0 0 0 0 0 0 BAFFLE ON THE OUTLET TEE. SEPTIC SYSTEM PROFILE TYPICAL SECTION o 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000 II II 00000000 N.T.S. h- 28"--1 F- 28 �O/� Closed End Plate Open End Plate c011 DESIGN CRITERIA . SOIL V DATE: AUGUST 18, 2020 (REF#15,879) NUMBER OF BEDROOMS: 5 BEDROOMS (4 IN HOUSE + 1 IN COTTAGE) SOIL EVALUATOR: PETER McEENTEEE PE WITNESS: DAVID STANTON R.S.HEALTH AGENT Z_____fr4l� SOIL TEXTURAL CLASS: CLASS III ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH 76 95.5 A 93.0 A DESIGN PERCOLATION RATE: 37 MIN/IN (0.25 GPD/SF) 0" 0" DAILY FLOW: 550 GPD SANDY LOAM SANDY LOAM 75 -I 34" -i 3 DESIGN FLOW: 550 GPD 10YR 4/2 10YR 4/2 1.25" 94.2 B 16^ 91.5 B 18" Side View End View GARBAGE GRINDER: NO SANDY LOAM SANDY LOAM HIGH CAPACITY INFILTRATORS, H-20 LOADING EXISTING SEPTIC TANK: 1000 GALLON CAPACITY (HOUSE-TO REMAIN) 10YR 5/4 10YR 5/8 PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY (COTTAGE) 925 Cl 36 900 C1 36" INFILTRATOR CHAMBERS LEACHING AREA REQUIRED: (550 GPD) = 2200 SF LOAMY SAND LOAMY SAND N.T.S. .25 GPD/SF 2.5Y 6/4 2.5Y 6/4 DISTRIBUTION BOX: 8 OUTLETS (MINIMUM) 87.5 C2 96" 88.0 C2 60" PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 8 ROWS OF 10, HIGH CAPACITY INFILTRATOR H-20 PERC UNITS WITH NO STONE & NO SPACE BETWEEN ROWS SILT LOAM SILT LOAM 96"/114" 2670 MAIN STREET, BARNSTABLE, MA � SIDEWALL AREA: NOT APPLICABLE 10YR 5/3 10YR 5/3 Prepared for: Cape Cod Septic Services, 350 Main St, W. Yarmouth, MA 02673 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF) ` Engineering by: SCALE DRAWN JOB. NO. (INFILTRATORS) 80 UNITS x 6.25 LF x 4.73 SF/LF = 2365 SF 79.5 1 1192" 80.0 1 156" P.T.M. 211-20 Engineering Works, Inc. N.T.S. DESIGN FLOW PROVIDED: 0.25 GPD SF 2365.0 SF = 591.2 GPD PERC RATE: 37 MIN./INCH ("C2" HORIZON TP-2) 12 West Crossfield Road, Forestdole, MA 02644 DATE / ( ) TP-2,"C2" IS CONSISTANT W/TP-1, "C3 CHECKED SHEET NO. NOMINAL BED AREA: 22.6' x 62.5' = 1413 SF NO GROUNDWATER ENCOUNTERED (508) 477-5313 8/28/20 P.T.M. 2 Of 2