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2701 MAIN ST./RTE 6A(BARN.) - Health
2701 Main Street, Barnstable A = 258 041 r .. `� _ � - 1, A• _ •� ' .. .. .� .. ' a . t a i -_ ., •,,�..,.rF :..>sta: .tea'=.. .: i1 � .f 3 y y, + 1 S ^* n u ti . r r, TOWN OF BARNS`3'ABLE (� U)CATION c �I Qa V CD SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. I= / ;�` �� � 3 (,, �9 2'3 �2 SEPTIC TANK CAPACITY LEACHING FACILITY: ( pe) /o LtNYf o9oCF1l4fNatX— (size) 37 X/R Y oZ r f,/a6 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: �-I �ci �7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet. Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200.feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I�O O ® �a \ w J No. Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migaal *potem Construction Permit '�� Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System El Individual Componen Location Address or Lot No. Z'7 O S d(L. Owner's Name,Address and el. o. n n Assessor's Map/Parcel /� N w 1..�, Installer's Name,Address,and Tel.No. 7 Designer's Name,Address and Tel.No. ,O �r(p/ ox-4- coc�4- 14 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(AP Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ►`+� Description of Soil Y�� Nam' -✓'� '_.,Qi�ivv✓ N e of Repairs or Alterations, nswer when applic ble) �-n ` 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$_oft nvironme 1 C and not to place the system in operation until a Certifi- cate of Compliance has been issu b th' and of Healt Signed Dat, Application Approved b Date 'y rr rr Y Application Disapproved for the following reasons Permit No. _ Date Issued `�— NO. Fee Entered in computer: THE COMMONWEAL-T-H OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for �N-4pozal-6p!6tem Construction Permit Application for a Permit to Construct Repair Upgrade Abandon El Complete System F-1 Individual Components Location Address or Lot No. Owher's Name,Address and el 0. '7 Assessor's Map/Parcel A X PJ-1 Lr4 Installer's Name,Address,and Tel.No. �Des2gnei's,&Le,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size? sq..-ft. Garbage Grinder(/W , 1 Type of Building t Showers Cafeteria(Other No..of Persons Other Fixtures Design Flow �61Z gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank —Type of S.A.S. --Z-*a--4 44 YVI D_escriptio of Soil L Nature of Repairs or Alterations(Answer when applicable) 0& L, n 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 Vtnvironmepn 5CP9 and not to place the system in operation until a Certifi- cate of Compliance has been issu this -65-rd of HealtV_ Signed Af Date_�5�:��ff Application Approved by Date Application Disapproved for the following reasons Permit No. 9 2 Date'Issued —————————————————————---———————THE COMMONWEALTH 0 1 F,MASSACHUSETTS BARNSTABLE, M' SSACHUSETTS Certificate of Compliance THIS IS TO CERT JFY,�at the On-site Sewage Disposal System Constructed Repaired Upgraded Abandoned by /IQ /P aten constructed in accordance MAWas been with the provisions of Tide 5 and the for Disposal System Construction Permit No. dated Installer Designer I / N 41 I)h�/�/C! ky The issuance of this-peng�sall not be construed as a guarantee that the syst vill function as designed. Date Inspector 1'1�7 _�;fllpA__a o Wom/y/c/ -7 7- No. -3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS �tg;po!w *Pqtem Conztructton Permit Permission is hereby granted to Construct Repair( )Upgrade( bandon,( -;;>- ')_j 6->at-?- 4n S System located at C) and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructj*on must be completed within three years of the date of this permit. -T_A1,9 Date: 7 Approved by a 1/6/99 II NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works i construction permit signed by me dated , concerning the property located at ®L U G/0 64AA/ . meets all of the following criteria.- The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A:S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W. Adjustment. 3 = DIFFERENCE BETWEEN A and B `3 Z SIGNED : i/ DATE: [Sketch proposed plan of system on back]. q:health folder.cert �. J � � c � � � � �: _ � �`�, � � r , � _ J /1\ i / 1 1 la�� t �� .` �-\ r _ �-----. - --- 1 Commonwealth of Massachusetts 61 Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a i' ty Property Address r Owner Owner's Name I I // T t .O information is berm' 61', d 7/a3/a0. required for every V 6 "1 f _ � page. Citylrown State Zip Code Date of Inspection �o f-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 A. Inspector Information / ���a� filling out forms on the computer; f use only.-the tab key to move your Name of Inspector cursor-do not ref use the return ; lit( I S 6 2 Q A-eli "S c y r)5� :key, Company Name �3 at Company Address 0 itylT` own State Zip Code 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 rpersonally 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 VPZ stem: 1. sses 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ .Fails 1 Inspec ors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or-greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer,.,if applicable, and the approving authority. 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.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro erty Address Owner , tv � C.q �:��y� b i d'klMqy t Owner's Name information is required for every &,rh S�gAjf Ma ng 03 G Z l a31anaLD page. Cityrrown 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: /WinIhave not fo any information which indicates that any of the failure criteria described 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 determ ned" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years Id*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or e xfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced wi h a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if i is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less t ian 20 years old is available. ❑ Y ❑ N ❑ ND(Explai below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts 1p Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ww % �701 2v4 � Property Address I���Ggd'h� Owner Owner Nasme information is required for every �d�n-S_d t 81-4 � c29CP 3 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): , ❑ Pump Chamber pumps/alarms not operatiJnal. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break oi it 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 repla ed ❑ 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 approv, I 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 eA aluation by the Board of Health in order to determine if the system is failing to protect public he Ith, safety or the environment. a. System will pass unless Board of iealth determines in accordance with 310 CMR 15.303(1)(b)that the system is not fui ctioning in a manner which will protect public health, safety and the environment: t5insp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Ogers Name � �— information is ��� �0 ?1a3/0�required for every V"oL 6'[. G�C��-- �� page. City/Town State Zip Code Date of inspection C. Inspection Summary (cost.) ❑ Cesspool or privy is within 50 fe t f a surface water ❑ Cesspool or privy is within 50 feet f a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of ealth (and Public Water.Supplier, if any) determines that the system is functions g in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil bsorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributtry 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 analysi , performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the pres ance 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 D. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Z.0 n o wee. plip)-e 4. Property Address ILI 7ohh U4 Owner Owner's Name �— information is required for every d'n �� r� !"d— 0,2 page. CityrFown 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 El or clogged SAS or cesspool ❑ 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 LVJ obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ The system fails: I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 1114 5) Large Systems: To be considered a largeVid 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"y s°or"no"to each.of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 eet of a surface drinking water supply ❑ ❑ the system is within 200 bet of a tributary to a surface drinking water supply ❑ ❑ the system is located in nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapp A Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewag e Disposal System Form- g p Not for Voluntary Assessments y ry Property Address Owner Owner's Name _ information is /►/� � .,^f required for every s4JrY�� r/ J_��� ``la?J1 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) V❑ 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 . s TRIOjL\ Com.monwealth:of Massachusetts f i l Inspection Form Subsurface Sege Disposal S.yetem lro�.t.INot far Voluntary Assessments Property.Andress �`/k ......if Owner Ownei's:Name informgtiorr is: � �-� ° : . aw 'req'it f0l eVely: d'r "v m _ .- _ f ._•s Page. Cdy rZ. State dip:Code Date.of Inspection 0 . syste.m. Information 1. Reslaential Flbw Conditions' � Num- ber of lo.Wrooms jdesign}: -- ---' Dumber of bedrooms(.actuai):: ......... ....... DESIGN flow based on 310 CIVIR 15.203(for example: 110 gpd.x#of bedrooms): Oescr�pfian; 4..4< -�: .... _ ................. _ _. _ ._ ... Number of current residents: --- --- Does:resid.Once lave a:_garbage grinder? ❑ Yes 8/", :Does:residence have a water treatrnent unit? ❑ Yes No Ityes,discharges to: is launOry'an a si° .ante sews e.s tern? include laund s.stein ins: ectidn p YS { ry Y p ❑ Yes P!o information iri ttiis repo t). Laundry systeot inspected? .0 Yes [5--'No :Seasonal use'? ❑ Yes C Na Water meter rsad'in s, if available last 2: ears Usage --—--_-- ---- 9 � Y 9 (91�))� Detail:: ..� .. 6 �00,A Sump p p um ? ❑ Yes [ No. Last:date of occupancy. '�. �•. :: y � c ,�` , , 1. Date i5tnsp.0=•rev,712001.18 Title SAWfidal ftpect(on F&#Siibwf!ace Sewage D106Ec fSOW.M Page 7 c1'96 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 01 n UT n d�ra3) Property Address J'ah h Cry �, �'r�zn,94�- Owner Mer's Nameinformation is �� �required for every ws� -bf r 00Ab 7/a3/2.0a� 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 syste ? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: fhb %✓ - % i Source of information: Y Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc.rev.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 Property Address —XAvi Lz Owner Owner's Name J information is ) required for every lC � '�b"� 6c9(P,?Cy 7 page. City/Town . State Zip Code Date of Inspection D. System Information (cunt.) 4. Type 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/Altemative 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): �Approximatp age of all components, date installed (if known)and source of info mation: f'7--1'3y Were sewage odors detected when arriving at the site? ❑ Yes ff/No 5. Building Sewer(locate on site plan): ���J Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑other(explain): 1p Distance from private water supply well or suction line: �A. feet Comments(on condition of1oints,venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `7 1 ovd-t 60 Property Address v� 1 Owner O716?"rh is Nark►e " information is n required for every - S, / 4(/7 04 to 3 -? page. City/Town State Zip Code Date ofi Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade��� feet 7Mat rial of construction: concrete ❑ metal ❑fiber lass ❑ polyethylene ❑ other(explain) C ank ism tal, list age: years age cc 1 d by a Certificate of o pli9ance?(atta h a copy of certifica e) ❑ Y s No Dimensions: �'" ��� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle O Scum thickness i Distance from top of scum to top of outlet tee or baffle 0 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 I vets as r lated to out le in , ev n e of akage, etc.): 1N_' > t5insp.doc•rev.712MOl8 T8e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 701 r Property Address Owner Owners Name information's i- t✓ .�J ?��3�� required for every 5 �D. page. City1rown 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 ❑ Iberglass ❑ polyethylene El 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 OL tlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, ir let and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, eviden a of leakage, etc.): 8. Tight or Holding Tank(tank must be pumprttimeof inspection) (locate on site plan): Depth below grade: . Material of constructon: ❑concrete ❑ metal ❑fit erglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 dal Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18. Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address —lei Owner Owner's Name v 4 L/ information is t /� t y� required for every -� 'C�CG�/� 001� '2� 7/,XY/DneO page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cunt.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float swit-.hes, etc.): "Attach copy of current pumping contract(r,quired). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) ((llocate 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.): ,/ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fomr.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 ProlSerty Address J �/hgl i1C e Owner Owner's Name information is /� � ? required for every -�rjo 5 �1 !y � ���a►3/�� page. Cityrrown tdtaW Zip Code Date of Inspection D. System Information (cunt.) ' 10. Pump Chamber(locate on site plan): s Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, ondition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, -ystem 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: leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 L I Commonwealth of Massachusetts Title 5 Official Inspection Form Y b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J 0 d Q�" s�� Property Address Owner O ers Name I information is ) required for every 7/d13/94,9- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, et , > CR'A�- -A, �14�11V 12. Cesspools (cesspool must be pump art 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 iydraulic 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 'd Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ? DUT G � Property Address / Owner Owners Name 1 information (pO�S � /�9 required for every `� �- � 7[o'31a�/p� 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 by, raulic 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 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address � 1 C +k� J4 M Owner Owner's Name information is required for every -SAL'¢ � page. CitylTown filate 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 landm rks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the ilding. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately f 3 / V � t s Y. 9 j 1 m - Pr, r� d t5insp.doc•rev.7/26/2018 T81e 5 Official Inspection Donn Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is � � required for every �n Z1 �� 0-a:6� 7��3/a.(r/�•G page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope �� /[Surface water 1,14?, ho / 2111c heck cellar � �i,� Shallow wells �1i9- � � 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 desb � O �� �—�' _ e how you established the high ground water elevation: Ae , G� v v 0 " Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is r14rh S; �)� /� /t �� / 7��3 /�ea, required for every `'���) .L—L.(� 1,,, page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: dA. Inspector Information: Complete all fields in this section. YB. 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE > LOCATION SEWAGE # VILLAGE__ �� �� 5��;,r ASSESSOR'S MAP& LOT R- INSTALLER'S NAME&PHONE NO. I= I, S i S . ��; (L SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /a FNYJRoCf AtA,.c_. (size) 37 X I X rFEc/J NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:U, 1- 7 COMPLIANCE DATE: I Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by s � f � t � ` 76 t � t . V .ZS8 TROY WILLIAMS SEPTIC INSPECTIONS _ Certified by MA Department of Environmental Protection (508) 585-1500 19 Hummel Drive South Dennis, UA 02660 COMMONWEALTH OF MASSACHUSETTS FgLalmaiigisg EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 'rrrLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Propert} Address: 2701 Main Street Barnstable,MA Owner's Name: Russell&Kathleen LaPorte Owner's Address. P. O. Box 184 Barnstable,MA 02630 Date of Inspection: March 14, 2001 . 0 Name of Inspector: Troy M. Williams Qj Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis,MA 02660 Telephone Number: (508)385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP appro%ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system- Passes Conditionally- Passes Needs further Evaluation by the Local Approving Authorit) Fails Inspector's Signature: 2.1•r.lO,� o Date: .31/y /o l The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original.should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. phis inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 pace 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 2701 Main Street Property Address: Barnstable,MA Russell&Kathleen LaPorte Owner: March 14, 2001 Date of Inspection: t 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 CN1R 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: iv119 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 indicatine that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2701 Main Street Barnstable, MA Owner: Russell&Kathleen LaPorte Date of Inspectiow .. March 14, 2001 C. Further Evaluation is Required by the Board of Health: NIA 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 "ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will.fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 2701 Main Street Property Address: Barnstable,MA Russell&Kathleen LaPorte Owner: March 14, 2001 Date of Inspection: 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 sewalge 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 clo22ed SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/I day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped . I/ Any portion of the SAS,cesspool or privy is below high ground water elevation. bL Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Nlq Any portion of a cesspool or privy is within a "Zone 1 of a public well. &L4 Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water . supply well with no acceptable water quality analysis. ]This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] /vv (Yes/No)The system fails. l 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: iv/A 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 2701 Main Street Property Address: Barnstable,MA Owner. Russell&Kathleen LaPorte Date of Inspection: March 14,2001 Check if the followine have been done. You must indicate"yes"or"no"as to each of the following: Yes No _ in2 information was provided by the owner. occupant, or Board of l Ieald 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 breakout? v*1 _ 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: Yes no _ Existing information. For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of 11. OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 2701 Main Street Property Address: Barnstable,MA Russell&Kathleen LaPorte Owner: March 14, 2001 Date of inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): G Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 6 • ���w:t . Number of current residents: a Does residence have a garbage grinder(yes or no): ,vo Is laundn on a separate sewage system (yes or no): wo (if yes separate inspection required) Laundry system inspected(yes or no): N/4 Seasonal use: (yes or no): Ajo Water meter readings, if available(last 2 years usage(gpd)): 79 /1,a _ 6 0dc; , yg/7y : 8 y�voo y 4���••r. Sump pump(yes or no): mo Last date of occupancy: COMMERCIAL/INDUSTRIAL At/,I 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: F „` - �,�i -w�.;.. �.�«:.].4• fy.,__. Was system pumped as pan of the inspection(yes or no): ivy If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM //Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank: _Attach a copy of the DEP approval Other(describe): Approximate age of all components. date installed (if known)and source of information: r.� s-b,.,; 14- Were sewage odors detected when arriving at the site(yes or no): vo 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2701 Main Street Barnstable,MA Owner: Russell&Kathleen LaPorte Date of Inspection: March 14, 2001 BUILDING SEWER(locate on site plan) Depth belo�k grade: a2 + Materials of construction:_cast iron /40 PVC_other(explain): Dkmricr fron. private water supply well or suction line: All � Comments(on condition of jo Wuints,,l�venting,evidence ot'leakage,etc.): J F I U S In�.�( I•N t S rA- -J C. tit✓ + t -/i w. Y ?` /H 3 y t c fi'J:n - . SEPTIC TANK: (locate on site plan) Depth below grade: fy' Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 7'X t 'x G' /S00 a Uo Sludge depth: y 11 Distance from top of sludge to bottom of outlet tee or baffle: ..2 Scum thickness:/ ' Distance from top of scum to top of outlet tee or baffle: y/ Distance from bottom of scum to bottom of out tee or baffle: G , Flow 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.): ���- ,C.t S W t✓�fi/,1?'U_i jr. _� r. 4.�/ ✓ �•n ....c�L e e.i.__ Al. �✓.��_�2✓.�.e 0 G/K �r�� s WAS /VV/1\✓ . �YNI� �/aY)L /tit NJGt�k V �^ JJ� /q ANN /)✓n�/V �7 GREASE TRAP:�is(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other. (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2701 Main Street Barnstable,MA Owner: Russell&Kathleen LaPorte Date of Inspection: March 14, 2001 TIGHT or HOLDING TANK: r�(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 Flo\�: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (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.): PUMP CHAMBER: A, A (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.): I 8 Page 9 of l l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2701 Main Street Barnstable,MA Owner: Russell&Kathleen LaPorte Date of Inspection: March.14, 2001 SOIL ABSORPTION SYSTEM (SAS): v/ (locate on site plan,excavation not required) If SAS not located explain why Type leaching pits,number:_ -7 leaching chambers,number: /o 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.): tlS t TZl / ✓✓.� v ✓ ) h dt CESSPOOLS:&V4 (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: k///I .(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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 2701 Main Street Barnstable, MA Property Address: Russell&Kathleen LaPorte Owner: March 14, 2001 Date of Inspection:' SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �4+y , A �SouyN�i„' ® O 6 i c �s 33 T /0 Chi ro c hf�.St.-3 Page I 1 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2701 Main Street Barnstable,MA Owner: Russell&Kathleen LaPorte Date of Inspection: March 14, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 3Z+ 'feet Adjusted high ground water elevation — feet Please indicate(check)all methods used to determine the high ground %Hater elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: S—`L�, . Observed site(abutting property/observation hole within 150 feet of SAS) ,L Checked with local Board of Health-explain: ��,r,a t.- 1, ✓' r<< k. Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: �ts Ic r c- . S < .l ro We 4 . ✓A o� t - cf �—r3 v e_ �� o .e, �.•.(s. J .tl.11c./.w .{ 1,�•L a't''Tv• J.L� ( G c ay L. H 4 S s.N . N 14 N �/J .J..f/� ../y. L_L�_ t�f✓:1 �s U h 1] r` O :^S No(1.-. ... r , FEB 1 f.................. THE COMMOTVVNEALTH OF MASSACHUSETTS BOAR® OF HEALTH .._.. �....VVV IV---......OF.....§jV.NYr1#L'E......................................... Applira#inn for BiipnsFal Workii Tonotrurtinn runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: A ...... .aY-&S a1 E...... .....•.•••----••-•••--•;..•-•.................................................................... ocation-Address Owner Address W Installer Address � Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ................................ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit---_................ Depth to ground water........................ f%, Test Pit No. 2--------;.......minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ •-------•----------------------------------•-----------•------------------•••--••-•-•-•-••......---•........................................................ 0 Description of Soil........................................................................................................................................................................ w W U Nature of Repairs or Alterations—Answer when applicable............�_'-:__.�� __�L.1...._L /� .__ ..� . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI.j 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i by the board offilalth Si e _ ,.. -----•----- .... ��- Date Application Approved By fa_, ........ Date Application Disapproved for the llow* re ons:---•-----•--•-----•---•------------•---•----••---•••-----•••-•••---•-----••.....---•--•----•--•--••------•••.... --••-•-•----------------------•••--••-•-•••-•-••---•--•-•-- ------ -••--•••••.......-------- Date PermitNo........................................................ Issued_........................................................ I � I tNo................_....... Fmc..........................._ THE COMMONWEALTH OF MASSACHUSETTS 7�- / /BOARD OF HEALTH...._.....1..0N_1-1..0N_N........... Appliration for Disposal Works Tonntrn.rtion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .. .ZQd../�!1r�1.%Y_-__S. .......................................................... -•-.....-----•-••-------••--••---••--------•-•----•---••--------•--....------...............•----- Loea�tion-Address • Lot No. �'.,�U1.%..------•---=--•------------------------- ......// sl.--- 111i�s.Y' -------------_-•-----__- W Owner - Address a .................... ........•^ Installer Address Type of Building Size Lot............................Sq. feet V Dwelling No. of Bedrooms.............................. .__..Ex Expansion Attic••+ g— --------- p ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total,leaching area....................sq. ft. j�: 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-__-_-_______--------__. P>4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___----_-__-___-----____ P4 ............................................................... -_........ ----------•-------••-----_--------_-•----------------•----------------- •----------- 0 Description of Soil........................................................................................................................................................................ x U ...........................•-••-------••-•----...............•---•--------•-•••-----••----....----------...-••••-----........---------•-•-----•-•---•---....••------------....-----••._...----._....---- W U Nature of Repairs or Alterations—Answer when applicable- $-_-_4�"AC-If__-).-IF•..._...... .---------•--•----.....-•----------•-------------------------------------------------------------------------•••----••_•-_•-. 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 bee&iyed by the board f health. ' I Signed...... . -_ / Date ApplicationApproved By----------------•-•-•---•----......••----.......-------•--•-•--•----------_____.....--------•---- ••--••----------....................... Date Application Disapproved for the following reasons---------------------••-•------------------------------------•-----------------............................... --.......-•............................................•--------•_....------.....-----•-•...------••--•-=•••--------------•---•••-•-••-------•---••---------•-•----•--••--•-------•---••--••------•--- Date PermitNo--------------------------------------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF .HEALTH .. yy*e7's, .............F .11��/.........0F..A+&Vxr,+,s4. &..........-.a r� .....,....................... Qlrrtif iratr of fP amplid"nu THIS S T CE IFY, T at t e,I dividual Sewage Disposal System_constructed ( ) or Repaired ( ) by............ � -� a QR _ at-az1N.-r__rr`- -----� l GT .I nstaller r7t1_114 --•---- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated___.-_____..__-_--__--__--..................... THE ISSUANCE O THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL U 1 N SATISFACTORY. Y /� DATE...... ....:........�••---------.........------------•---...------. Inspector. -•-------•---------...---------------•---._.......--------.............---.....-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7� ...........................................OF..................................................................................... No......................... FEE........................ �to�ro � r '5Tonntrnrtion annt Permission is hereby granted_... _ to Construct "}� �epait a� Indiavi al Sewage Dispos�3� y atNo--------------------•-•-----....•-- --••----...........----...---•......•--...----•-•--•-••.----•-•._......... ..................................................... Street as shown on the/ap 'cati n for Disposal Works Construction Permit N �_____________ Dated.......................................... Ae / Board of Health DATE..................... ......................................................... FORM 1255 A. M. SULKIN, INC., BOSTON z �- — b b i 3 T 1 e - Q .� c s l000 �c sk j . r s LOCATION SEWAGE PERMIT NO. `'�.a7ol z✓&� YI.LLAGE INSTALLER'S NAME i ADDRESS a 9 1 L 04 R OR OWNER DATE PERMIT I S S V E 0 DATE COMPLIANCE ISSUED °. i ct? O P -� No. ....._... -• � 41 Fps....................... .... 4. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF -HEALTH Apliliration for Diipniial Worko Tongtrurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at �. ...........s _� .............A.411V..::��.Afiz115 .�....................................•---.... ...... - Loc o...>.. Lot No. es -••.......................................... ........ Owner Address w 2 �4 0� v- o nr S l o) �. a .............. .. ........ Installer Address Q Type of Building Size Lot............................Sq. feet aDwelling " No. of Bedrooms...... Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons-___-____-______--_-.._----: Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------------------------------•--•---•-----------------------._......•-------------•-------------•------•---•-••-••----•---- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No---------------- --- Width.................... 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...................................... aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water____-----____-__-__-_--. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Ra ----------------------------------------- ---------------------------- -------- •-...... .------------ ---.......................................................... ODescription of Soil....................................................................................................--------------------------------------............................ x w ----•--------- - ------------- ------------------------------------------ ----------------------- ---- ---------------------------------------- ------ 3 -------------------------•C------ UNature of Repairs or Alterations- Ans r when ap ;cable._._ ; '--!-,,__......_��.. ...�'_�:L:=`.._...Ep.t......C:.___. W n1 IC._ ' T ,, ,�J �g .....................................r__ 1us:'.�C�_ P___:_.:Gsc....�/. Jc b n..._�-�� � .,......._.__......__._.... .._.___.____._..._..._......__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTI_ y g g*not y5 of the State Sanitar Code—The undersi ned further a lace the system in operation until a Certificate of Compliance ha sued by the oar of health. Signed .... �- Date Application Approved By....... r '" �---- ......................... ....(. . =: e--•--- - Date Application Disapproved for the following reasons------------------------•---------------------------------------------------------------------------------......_ •.............•---......-----------•--------------------------------------------------.................-------------••-----------•----------•-•-•------------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date No. -d••!. .1 FEE............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....--.....OF.......... .¢ '` *`/-- ---------------------------- Appliration for Uinpnaal- Works Tonitrnrtion "ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Loc o A e or Lot No. ..° _k. - ... .` . ................................. ..............................................................-...•----.-_..........-----. - ..,. W �*]p kt �j Owner Address IV !!." v Y Y.. 0 -____--•--------------- -----------------------••---------_............................................................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling o. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type g _______________ No. of persons____________________________ Showers ( ) — Cafeteria ( )Other—T e of Building _____________ Q' Other fixtures -----------•----------•-• ----•- . W Design Flow............................................gallons per person per day. Total daily flow......................._............._......gallons. 1:4 Ptic Tank—Liquid capacity Length hidth--.-'- ~ _ Diameter_______________ Depth................ Disposal Trench �o -- - �d�h Total Lengt - -__ __ 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_____._______________,__. �T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................... a •------••------••---•--------••--•---•-•-------•--..._.--•-•---------•••..........................•.......................................................... 0 Description •••-----••-•------•-••--••..............••-------••-•--•------------•------••-----••-........ ---------------------------------- V ..............................................o -•-•-------'.:.-----•. ----•-r------•-------------••-----------------••----------••-•--------- '-----...-•-•------•----••--•-----...------. W -------•----•• -• -----------•--------------•-•-•- i-- ---------------_---- -•----------- - U Nature of Repairs o, Alterations Ans e when applicable ___________________________________________ �............................' '� °• ----------------- ------------------------------____----- Agreement: ". . I The undersigned agrees to.-install the aforedescribed -Individual Sewage Disposal System in accordance with the provisions of i T T LE 5 of the State Sanitary Code—The uncle igned further agr*,ndtce the system in operation until a Certificate of Compliance ha ued by he and f health. Signed----- f �---- -- -- -- - -•- -- _.4 Date, Application Approved BY----- �"` At. ....-- � �-------- -----••-- .........................' Date Application Disapproved for the following reasons---------------------------------------------------------------•••--•-------�: -------------------------------------------------------------•-------•----•-----------.......---------•--------•--------------•------•-••---•--•-----------•••--------1--------------•--•------•--•----- f' Date PermitNo............................. .......................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......OF..... . . '' r . " ....... ....................... ......... (9rdif irair of Tompliane TH , IS TO CERTIF 0., That the Individual Sewage Disposal System constructed ( ) or Repaired All by '"t �- ' �.. B ,I, taller t at = "W` ° has been installed in accorda*i� with thre.provisions of ^jj_.'E 5 of The State Sanitary Code as describ�d.in the application for Disposal Works Construction Permit No _%_ ____ ... .. ' ' -------•--- .` dated THE -ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL fUNCTION SATISFACTORY. .,,a. DATE...:..... 1! ._..�t.�---..........-----------•-•-•••••--••-•.._._. Inspector. y4 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF,,HEALTH ...... ...............OF.--- . .® . ...._..........._.__........................._.... N ..... FEE........................ aillp"1141 Irvrk %,_, "n�tr i�an amit Permission is hereby granted.._ _ � ..._ _.. y to Construct ) or a an Individual Sewage Dis ©sal S tem .............................................................. Street as shown on the application for Disposal `forks Construction Pexfhit No ___z _____ Dated____` '.- Board of,He- i:l DATE... .'" ": �" t - FORM 1255 HOBBS & WARREN. ING-;'PUBLISHERSV. ;,ra . -