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HomeMy WebLinkAbout2730 MAIN ST./RTE 6A(BARN.) - Health a 2730 MAIN ST./ROUTF 6A, BARNSTABLE r . A = 258 062 1' n 5 25 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .t 2730 B Main St Rte 6A Property Address , Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every 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. ^ A. General Information 1. Inspector: Shawn Mcelroy .t 'Q Name of Inspector Upper Cape Septic Services t a m Company Name ! -- P Y 29 Atwater DrrUU ' Company AddressLL ' E. Falmouth MA 536 O City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification t I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 1.5.000).The system: ® Passes ❑ Conditionally Passes, ❑ Fails ` , ❑ Needs Further Evaluation by the Local Approving Authority 5-8-08 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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate:regional office of the DEP.The original should be sent to the system.owner and copies sent to the buyer, if applicable, and the approving authority., ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: ` System is in good working order with no sign of failure. a" 0 B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved.by� the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts ` . Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2730 B Main St Rte 6A :, , I " Z t Property Address Suellen Garner •+._ k. `, Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced w ND Explain: w •. „ ❑ 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: 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 ofa 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. t5insp-03/08 "- - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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: Y PP Y 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/ day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form;.Not for Voluntary Assessments , '< 2730 B Main St Rte 6A f Property Address Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every page. City/Town •State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont): • . , is. :4! 'j .. t.+ :. .. ..-,p. - . t+^ ! � - a� :;--)._ .. � i Yes No I ❑ ® 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. [Phis 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- 10,000dpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the"failure. 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. r 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 ❑ El 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every 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 E ❑ 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? El ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) E ❑ 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 CM 15.302(5)] t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5, Official .Inspection: Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 2730 B Main St Rte 6A Property Address Suellen Garner - t Owner Owner's Name information is required for Barnstable MA 02630 5-7-08. every page. City/Town State Zip Code Date of Inspection D. System Information . Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of,bedrooms): 330 Number of current residents: Does residence have a garbage grinder? �," ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] .. ❑ Yes ® No Laundry system inspected?` ` ' , ❑ Yes ® No Seasonal use? El Yes ® No Water meter readings, if available-(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: . 5-7-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: r , Design flow(based on 310 CMR 15.203):, = r ' t r't °•� n- Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ~ Grease trap present? a E - z "❑ 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: Last date of occupancy/use: Date Other(describe): t5insp-03/08 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7,of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner--pumped 2 yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason forpumping: Maintenance 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 b system operator under contract P Y Y Y p ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts -�- Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form_Not.for Voluntary,'Assessments. ± , M 2730 B Main St Rte 6A -i.rA Property Address Suellen Garner t Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet 1 t 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.): Septic Tank(locate on site plan): t 8 Depth below grade: feet Material of construction: :• Z 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 Gal „ - Sludge depth: 10 Distance from top of.sludge to bottom of outlet tee:or baffle { 22" Scum thickness,. r t.„ ,. Distance.from top.of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? Tape t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts r W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every page. City/Town 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.): Tank in good condition with all baffles in place. 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.): 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): t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 I f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments t. 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is required for Barnstable -MA- 02630 0-08 every page. City/Town rState Zip Code Date of Inspection D. System Information (cont.) ' Tight or Holding Tank(cont.). Dimensions: ; Capacity: gallons Design Flow: • gallons per day Alarm present: ❑ Yes ❑ No 4 Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: , Date Comments(condition of alarm,and float switches, etc.): t Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): a Good condition. Pump Chamber(locate on site plan): i Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts x W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is Barnstable .1 MA 02630 5-7=08 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 ❑ 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.): Leach pit in good condition with historical stain lines at 16" below inlet invert. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts �.f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ y 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) z 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 El Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ..rr 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•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. I o„f Q r}' G t� - � _f f AD ay' _F 5'/, Q_F 33� t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2730 B Main St Rte 6A Property Address Suellen Garner Owner Owner's Name information is required for Barnstable MA 02630 5-7-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slopes ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 40' feet Please indicate all methods used to determine the high ground water elevation: ❑ ` Obtained from system design plans on record . a t 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: Town maps show groundwater at 46'. t5insp•03/08 i itle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable Op THE T� ti Regulatory Services BARNSPASLE, ; Thomas F. Geiler,Director v� ib M `�� AjF1619. Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 , Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department,of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted sp the inspection. aF Town of Barnstable P# `3t3 Department of Regulatory Services i : Public Health Division Dater 200 Main Street,Hyannis MA 02601 Date Scheduled Time ` Fee Pd.-2®C �--- Soil Suitability Assessment for Se age Disposal Performed•By: �7D4,ug,—> cF. n?450 Witnessed By: LOCATION&GENERAL INFORMATION Location Address (77/� ) � 6 Owner's Name J'�K (/• J(/ �`� � Address R2—s0 94— b Assessor's Map/Parcel:-0 506zod,4 Engineer's Name— qy j L, 'j p1��6-V NEW CONSTRUCTION REPAIR y Telephone# Land Use' Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Une ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) A V I Parent material(geologic) . I Depth to Bedrock Depth to Groundwater. Standing Water in:Hole: Weeping from Pit Face Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL-HIGH WATER TABLE Depth Observed standing in obs.hole: In, Depth to soil mottles: Dep in. , th to weeping from side of obs.hole: ln Groundwater AdJustment In Index Well# Reading Date: Index Well level .,_• Adj.}+actor•�„y Adj.Groundwater Level_ 1 l Observation PERCOLATION TEST Date_,. Time �f- • Hole# r{ Tuna at 9" Depth of Pero Time at 6" Start Pre-soak Tme @ rime(9"•6") End Pre-soak • • � 'I V ' Rate Min/inch Site Suitability Assessment:' Site Passed Site Failed: 7 Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'.of wetland,you must first notify the. Barnstable Consell'vation Division at least one(1)week prior to beginning, Q:\.SEPTIWERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil. Surface(in.) (USDA) I . �± Other (Munsell) Mottling (Structure,Stones;Boulders. D o�istencv 96 l3rav Il .......... R' 7 o D, be DEEP OBSERVATION H Depth from HOLE LOG Hole# � p Soil Horizon . Soil Texture Soil Color Soil Surface(in.) Other(USDA) (Munsell Mottling (Structure,Stones,Boulders. onsi en % ra e cSr� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(I".) (USDA) (Munsell). Mottling (Structure,Stones,Boulders. i to DEEP OBSERVATION HOLE LOG Hole# Depth from .Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA). (Munsell) Mottling (Structure,Stones,Boulders. consistency, Flood Insurance Rate Mau: Above 500 year flood boundary No— es Within 500 year boundary No Yes Within 100 year flood boundary No. Yes,:......_ Depth of Naturally Occurring Pervious Materlal Does at least four feet of naturally occurring perviou ma rial exist in all areas observed throughout the area proposed for the soil absorption system? If.not,what is the depth of naturally occurring pe ious material? 1% Certification ` I certify that on 1047 1 (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was pe t red by me consistent with . the requir ing,expertis nd e ' nce described in 10 CMR 15.0'. Signat a Date ` Q.WEPnL-\PERCFORM.DOC Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key V to move your Scott Campbell Jcursor-do not Name of Inspector use the return key. Cardinal Construction Company Name , 32 Ridgetop Rd. Company Address Cty/T Ma 02635 City/Town State Zip Code 508-420-1295 S 1388 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 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 urther E luation by.the Local Approving Authority 7/25/2011 Insp oe! Sid'At Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how.the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:,Subsurface age Disposal Syste •Page of 17 t t Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 2730 Rte 6A Unit B_ Property Address Suellen Garner Owner Owners Name information is required for Barnstable Ma 02630 7/25/2011 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ; ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) f 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): C ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma - 02630 7/25/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (coot.) 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 r or clogged SAS or cesspool El ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments ,M 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont:) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. 1 ❑ ® 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. f 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 II ❑ 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every 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? ® El available 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): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 V-NM I Mol"I 11 1%7F%&%FL1v4wF1 1 5 %w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 2730 Rte 6A Unit B Property Address Suellen Gamer Owner Owner's Name information is Barnstable Ma 02630 7/25/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years.usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current DatCommercial/industrial Flow Conditions: r Type of Establishment: Design flow(based on 310 CM 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts mom T�fln SZ In&--r+or•finn Pr%rm Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 2730 Rte 6A Unit.B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every page. Cityrrown 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: 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-11/10 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 , s 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line- feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 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: t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 I � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments } 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable . Ma 02630 7/25/2011 every page. CityrFown 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 4'.3" Scum thickness Distance from top of scum to top of outlet tee or baffle 4„ Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? tape measure and sludge stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): system should be pumped every two to three years depending on the amount of useage.Tees in place at time of inspection. System liquid level at proper working height at time of inspection. No evidence of leakage at time of inspection, into or out of septic tank. r 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every page. Cityfrown 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every 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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is set level with one single lateral line. No evidence of solids carryover to box. No evidence of . leakage into or out of box. 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: m I 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every page. Cityfrown State Zip Code Date oflnspection 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.): (c) No signs of hydraulic failure, no ponding ,no damp soil, normal vegetation. (grass) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 .every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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-11/10 Me 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every 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 C� W r �v U t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2730 Rte 6A Unit B Property Address Suellen Garner Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 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: Perc. test at property less than 35'away from system. 2730 Rte. 6A unit A Certificate of compliance issued on 7/26/2011 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 2730 Rte 6A Unit B Property Address Suellen Garner' Owner Owner's Name information is required for Barnstable Ma 02630 7/25/2011 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN r BAR STABLE SEWAGE_# VIL.., GE � ���� ASSESSOR'S AO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS i BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: j 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 s� v �, cti - .� O Q' °� e�` ..� o� (T �s i c� F� _,`y _ ���� �., a� !� _ � _� —�- r� � . ; � ..� /TOWN OF BARNSTABLE hLOCATIONo 3 bl 7 SEWAGE *ir•. i�ILLAG ASSESSOR'S MAP&PARCEF9 INSTALLER'S NAME&PHONE N r SEPTIC TANK CAPACITY 1090 „-alto d LEACHING FACILITY:(type) NO.OF BEDROOMS OWNER PERMIT DATE: AMCOMPLIANCE DATE: %' Separation Distance Between the: Maximum.Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac'i facility) Feet FURNISHED ���4,L,�.�A�� s r Y Y No. =� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpfication for disposal 6pstem-Construction 3permit Application for a Permit to Construct( ) Repair(iT'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.L p 4' Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 91W jAst_al`ler's Name,A dress,and Tel.No. I designer's Name,Address,and Tel.No. r-vv i A,$G k Sig c{Zvi O Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets / Revision Date Title Size of Septic Tank 14A( Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) G Date last inspected: Agreement: The undersigned agrees to ensure the construction aintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the ironme tal C de and not to place the system in operation until a Certificate of Compliance has been issued b this Bo alth. i Ai O Date G 2G Application Approved by - Date Application Disapproved by Date for the following reasons Permit No. '� Date Issued No. Fee 0 -'`�``---- THE CO ONWEALTH OF MASSACHU60I T�" Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplicatlon for *49sal 6pstem-"C645truction Vermit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.Z 30 6 /�' Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,A dress,and Tel.Np. fDesigner's Name,Address;and Tel.No. z.: JCS (f X p?--I �°6�"�1:�- , F Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) a Other Fixtures ' 'Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets / Revision Date Title , � Size of Septic Tank&- -„:D Type of S.A.S. L�' Description of Soil t 1 Nature of Repairs or Alterations(Answer.when applicable)zz ,,�, T �� T Date last inspected: , Agreement: r The undersigned agrees to ensure the construction aintenance of the afore described on-site sewage disposal system in r accordance with the provisions of Title 5 oironme tal C de and not to place the system in operation until a Certificate of \ Compliance has been issued b thAdq h. ig p G Date V Z �Z Application Approved by p 1 _ Date Application Disapproved by Date for the following reasons Permit No. Date Issued i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifi rate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) ` Abandoned( )by., at 4 73o Op A has been constructed in acco d ce with the provisions of Title 5 and a for Disposal SystemConstruction Permit No. ated Installer(.�'✓���� h13.i`°l_.Cfi�B�y Designer Q (� #bedrooms 3 Approved design flow 0 gpd The issuance of this permit shall not be construed as a guarantee.that the system wll functions ned. Date Inspector ---- No.--------------------*THE - - - - = - •--- = - _ - - --- _------- --------- ---------- = Fee COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Nsposal 6pstem Construction Vermit Permission is hereby gra ted to Construct( ) Repair( ) U gra e ) d ( ) 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. , 1 Provided:Construction st be con- ete within three years of the date of this permit. Date Approved by , a • b r TownrofBairnstable SINE ram, Regulatory Services ti Thomas F. Geiler,Director &UMST^B Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: D�( l� Sewage Permit#aAI l Assessor's Map/Parcel#c9S 8-_.61?_1/4 Installer&Designer Certification Form Designer• � 1.1D •`^'� 'y Installer: L4QI>t4 Address: Address: On z� ' l ( v�1 o4•t_. ,was issued a permit to install a (d te) (installer) septic system at OS(� L based on a design drawn by ,� C ddress) y• dated C 6 (designer) <certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of t e septic system) but in accordance with State & Local u- -tions. Plan revision or 41nsta d as-built by designer to follow. Stripout (if rP- cted and the soils ound satisfactory. N FF ti1q v DAVID sy�y 0B. ' ignature) MASON j y No.1066 SST (Design 's Signature) PLEASE RETURN TO BARNSTABLE PUBL._ OF COMPLIANCE WILL NOT BE ISSUED UN i iL lsu i ti i tug r(ARM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertification form.doc TOWN QE BARNSTA BL:E 0 LOCAMN SEWAGE VILLAGE , E� ,—1 S kiL ASSESSOR'S MAP&L.OT�..� . JNST.ALI ER'S NAME.&PHONE NO. ...�. ..,.. ,' SEPnC 'TANK CAPACrrY I LEACHING FACILITY: 10, — No.opawRoGmS.3..� �. BUILDER OR O R. PERMT T'DAT'E: --..,....��-.:_ f�+oWLJ NGE Separation Distace Between the, Maxhnum Adjusted,Crotandwrater l4ble to die Bottom of Leaching,Pacility i Private Water Supply Well mad Leaching Facility (If any swells exist on site or within 200 feet of leaching facility) Edge of Wetland and Lear.,lting p'acility(if any wetlands exist Within 300 f l t��tl ft+ �J+) Fur*had b fQovH Q f z i FroAtn c -D- do' a-19, a -�- as' acl 'OWN OF BARNSTABLE )CATION SEWAGE ':LACE ASSESSOR'S MAP & LOT STALLER'S NAME & PHONE.NO. 'PTIC TANK CAPACITY` F :ACHING FACILITY:(type) (size) '). OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 'ILDER OR OWNER iTE PERMIT 15SUEli: �TF CONPLLANCE ISSUED: RIANCE GRANTED: Yes No � sr �tk- r Q Slio Yo v S c -� Sever Permit ,,o am e Location Yo Installer's Name and Address , Builder's Name and Address�� Date Permit Issued! 'Date Compliance Issued: �Ji � -, ' � . a � �" ` ,� � / 1 ��� �` \`� y= -�-� © �> ` �,f�y: �' �p. �> ' � $ n I "'f Sever Permit Tlo . Nto game s/V.---1�--�a - ----__ _------_------ ------- Loc at ion � �- - ...— 1 t' .---------------------- 5 � Installer's 'T,iame and Address ' �l Builder's Name and Addres s Date Permit Issued! _ Date Compliance Issued' _ r i - 3 IZZ c-- r i FEs................s.No .....,< :.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. ........................OF.......................................................................................... Appliratinu for Dispnnttl Workii Tnnntrnr#inn amif Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: , X:. .......-•-•--...-----.••-•-• -----•................•••-••------••---------••....._.._....•-•---.........._.............-----•-- ation Address or Lot No. q.......... . .P.l .�' ......................... ........._............._.. .............. W -•-• Owner `���D Address a ...... ... ..... ..... .... ...... s ........................ ...-............................................... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms....... _ .__..Expansion Attic ( ) Garbage Grinder Other—Type of Building No. of persons............................ Showers a YP g ------------------••-------- P ( ) Cafeteria ( ) Q' 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 ( ) ' a Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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........................ p� ....----•------------------•........----....----.................---•--..........-•-••-••--••----.....-•----..........-----........-------•-•••---..I._....._. 0 Description of Soil........................•------------...........-••-•-•-•••-•--...----•----•••------------------------...........---------.....-------•---------------........-•------ U ----•------------------------------------••-----------------------------. ..•----.........---•-• ... -------------------•-•-----••--------.-----.-..------------.--•------------ --------------------------------------------------------------------•--------......----•-••---------- I ------. • -- / U Nature of Repairs or er Answer,�hen applicabl l .: .... ..._ �.1._�..... / _L.. . ------------------------- ?�....---•- ....141 .........1--t_ ....C�....--•-•----•-•--------:..---------------.........---------•----...._...........-•---------.........:....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 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 ed by the boar of health. ............ ......... ........ .....--.... Application Approved ---- ...... .......................••---•-------•--•----.....-•-•---•---•--------....---• /... . _ ate Application Disapprove or a following reasons:......................................................................................................... .................................... •---............................................. ....•• .. ............------....... •.......................................................... Date PermitNo....................................................... Issued................................................ Date -------- -_ - - --------- - - ----------- - ' CiIE3 r No.................._....... FEs............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ...................OF..........................................._..... ApplirFation for Uiapwi al Works Ton,strurtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ti Addre or Lot No. ................... ............................r� � ---.-----------------.- Own p Address Installer Address UType of Building 3 Size Lot.................... .....Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—Type of Building No'. of persons............................ Showers g ------•-•--------•-•••-----• P ( ) — Cafeteria ( ) 04 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........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -•-----------•-•••-•••-••••••--•--.......-••---•------••--------•--•----------------•--••------•----•---••-•---•-•-•-•---•-----•.......--••----•-•••--.---- 0 Description of Soil........................................................................................................................................................................ x U .........................................................--•-----........----------••-----------•------................................................................................................ w UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------•-----------------------------------------------........--_.....•••......---••-•--•••----•--•-•--•-•--•----•---•------•----••-----•-•••-•.......----................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl' c as been ' ed b the bo of Health. Sig e CGS- ./C)-•-Z-6 •-•�•- ApplicationApproved BY• •-- •-------••-•---••--•---•-----•--•----------------••---...............------........-_.... Date Application Disappro�v r/>(fte following reasons:------•-------••-•------------••---••-----------------••--------- ............................................ ..-•----------------•-----------------------•---•------------•--...------.....-------•-•--------..•......._.....--•-----.....----•---------------•-•-------------•---------••••------•-••-----.....--•--- Date PermitNo......................................................... Issued-........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... .� � .nf f�I1m�littnrr T1Y I SDt2ER vidual Sewage Disposal System constructed ( ) or Repaired ) by........ -- •--------- -- •- --•-----•---------- •---••-•---------••-•--•--•--•-----•-----•---••-------------------•--•-.....-•--••...._..--.••. eC / �� Installer at............................. • . ......:....-------------•-•...----------•-------•--•--•••-•-----•---•...---•--.....---•-------.....--•-•-- ........------•--• ---•----- ----•----••----••---- has been installed in accordance with the provisions of Te13 --5 i/Ae State Sanitary, e�/ s in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU A GUARANTEE THAT THE SYSTEM 1AlIL FACTION SATISFACTORY. t DATE__ ..1r __ Inspector.... .. -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS �3 ��/� BOARD OF HEALTH ..........................................OF.................-•----•-•--......................--•--•---•-•....................... No......................... FEE........................ W11 ramit Permissionis hereby a .='•-•...._ .... ••. .........--•-•---.-•-------•-----•-•----•••--•••--•--..._....••--•••--•-........---•••........................... to Constr V )jon Rep9 l .ual wage Disposal System atNo. ---•------•-•--...-•-•••-------•-••-•---•-----...-----•-----•----••..............•-....••--....... ----Z Street , �as shown on the a lication for Dis osal Works Construction Permit No..PP P , --•-=.'--- Dated--- ------••.............. • -------- -- -- - -------------•--•----------------- •--•----•---- Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON TOWN OF BARNSTABLE LOCI�TION oZ J, � ��� � SEWAGE # l.3-�.� VILLAGE , ASSESSOR'S MAP & LOT INSTALLER'S -NAME & PHONE NO. -3085 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) QD� �� (size) NO. OF BEDROOMS PRIVATE WELL O PUBL�WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No.,- ' 7 _ I'•f +r ci r1o ���' Y" Al r , V No.. ...... THE COMMONWEALTH OF MASSACHUSETT S BOAR® OF HEALTH TOWN OF BARNSTABLE M-41"t - i u i Wi nrki Tnnitrnr#inn rrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ------ 1'on-Addr• s or Lot No. ........--- ..._... ---- ---•.. ----•.................... ............ .......••-----•-•---•---....---•---••-------..•...•--•-•----•...---•-..........-•--•- W _ - �=;o C�t -•-•--------Address ......• -- s -•- . ... ............•...................••....... ............................... ....•-•._...............-•-•--•............ r Address T of Building Size Lot............................Sq. feet ,.., Dwelling— No, of Bedrooms.......... ---------------------_--------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------• No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow...................._.......................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........................................ a Test Pit No. 1................minutes per inch Depth of.Test Pit-................... Depth to ground water........................ fY Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •-••---•........................•-••-••-••-••----•••--••••...--•....--•--•••••-•••••--•......--••••-......................................................... ODescription of Soil........................................................................................................................................................................ W V .........................•-•--••----------•-•-•----.................-------••--•--••-•••-•...........-•-•••-•---•-------•--.._..•---•---••--....----.....-•---•......••--•-•-------•-•-•................ W ---------------------------------------------------------------------------------------------------•----•----- .... U Nature of Repairs or Alterations—Answer when applicable.______ _ __ __________________ ____ ____ r,._._e........_. -••-------------------------•------------------------------•-•-•---•----------------.................---••--------------------------------------------••--.. ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been issued by t e board of health. Signed .. ----------- ... ..... .. .... .. . .. .... ...................... -.� .'.. ...-...f�-3. Dare Application Approved By ....... - C ................. . ... ............. Da e Application Disapproved for the following reasons: ..... ........ ......... . . --- .... ................................................................................... .............. ................................... . . .......... .... ........................................ �y I?are -.....-..-- 9 Permit No. -.. - ----..- Issued .........[-.......f. THE COMMONWEALTH OF MASSACHUSETT V S BOARD OF HEALTH TOWN OF BARNSTABLE Applirattun for Uiupuuul Nurk,s Tonutrurtiun Funtit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............. . 7-14. --- .. .................................................................................................. Lot N o :�tion-Addr• s t ' or o. W Owe r .............—......• Address a Ins er Address Typ of Building Size Lot............................Sq. feet g— : -•--_-•--_--•-------- p' ( ) Garbage Grinder ( ) ►-� Dwelling— No. of Bedrooms.__...._. Expansion Attic aOther—Type of Building --------------------------•- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) ' Other fixtures ------------------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. jW Septic Tank—Liquid capacity........._gallons Length---------------- Width---------------- Diameter--- ............ Depth................ x Disposal Trench—No. .................... Width_.................. 'Total Length.................... Total leaching area....................sq. ft. 3:r 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (Z4 Test Pit No. 2................minutes per inch Depth of Test.,,Pit.................... Depth to ground water........................ 0 Description of Soil------•--------•-------------------------------------------------------------------------------------•------------------•-------------------....--------•••-•--•--...... x WJ............................................................................... ............`....__....._...__....____......_.._........_..• --------- ................................................................................................................... .. U Nature of Repairs or Alterations—Answer when applicable.___._. _ __ ._ -tf?,-................. ....----•...................•----------------------•----•--•----------------------------.....-•------------------------------...-----------------------------...-•-----•--.......--•---...._............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposa'. System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance bias been issued by the board of health. ' - -- Signed .................C•` ,- --...--- .._✓- Dare-..../...:._.... Application Approved B ------- .. k... - ...o........ /....1.. ........................ ........ ........................................ PP PP Y �1 � f r� UDare Application Disapproved for the following reasons. �. . ................................................................... . ......................................... ............................................................... a..../'..... .............. ........................................ i Permit No. .....1...: �----"----------- V /....... .......... Issued � �. �� �m,•�. _z s_,----- THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH TOWN OF BARNSTABLE QVI.ertiftirate of Tantylianre THIS IS -0 CERTIFY, That Individual Sewage Disposal System constructed ( ) or Repaired ( ) r .�..V.I ��.....y ................... o........ _ ... a... b n......................... r. 1:: has been installed in accordance with the provisions of TITI.L 5 The State Environmental Code as described in the application for Disposal Works Construction Permit No. ._V���'-'.... ...._...� dated .....................__................ ...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST�AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........- .......�...'..... .......................................... ---- Inspector --- ------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No...r ........... FEE... .................. �i��.uutt1 Turku �unutr1 Urari �rrmit ,- Permission is hereby granted' <P0�-----:�i / rr /"; ........................................................ to Construct (� or. Repair. ( ) agn Individual Sew _ge Disposal S'�y; ie at No......... -...... _1 A/ a � l�C----l.� ..... r ;J-- --- -----4- ..,_... _ ...,._ r street „i as shown on the application for Disposal Works Constructi4 n Permit No.-._.�-__.-._� �ted..__�?..............................!?.. ...........67 Board of Health_ DATE................ y ....... .......................... FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS I :c� fir: DATE. 9�/' $/,�5 PROPERTY . ADDRESS:: 730. Route 6A" t Barnstable,Mass . . ? 02630 On the above date, I inspected the septic system at the above address. This system consists of the-;following: 1 1:-1000. gallon septic `tank 2: 1.-distribution box: _ 3. -2-600 gallon leach pits Based on my Insvection, I certify the following conditions. 1 .This is 'a title Five se' tic.:. s s!tem:, ' 2. . The peptic 'tank_ sho.uld,_be' pumped-. 3:The 's.eptic 'system'.is lri proper working order at the, present_ time. - ) it • • . A - _ c' SIGNATURE: , Name: J_P_M_acomber Jr... i Company:_J.P.Macoi0ber. & Son* 'Inc Address:_-Be�c-bb--- F fcff Centerville Mass : oCT �f® .1996 Phone: in, // THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY. IM51im JOSEPH P. MACOMBER & SON,. INC. Tan.ks•Ceupools-Leschtlald: Pumped & Inststled Town Sewer Connections P.O. Box 56' Centerville, MA 02632-0066 a 773-3338 77"412 M1 'LI) Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection C i William F.Weld Governor . Trudy Coxe • Secretory,EOEA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: .2730 Route 6A Barnstable Address of Owner: Date of Inspection: 9/26/95 (If different) Name of Inspector: Joseph P.Macomber Jr. Company Name, Address an Telephone Number: 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 i and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems, The system: •Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority } _ i _ Fails c Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: /I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. >. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: i A'Y` One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass,inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of.Health. „_ •^' (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • .,,Telephone(617)292 5500 (,.e-. SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM I PART A CERTIFICATION (continued) I , Property Address: 2730 Route 6A Barnstable Owner: Arlene McCullagh Date of Inspection: 9/26/9 5 B) SYSTEM CONDITIONALLY PASSES (continued) t, Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 j . i • i - I Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 4 _4Z - Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment.. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT I THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system nas a septic, tank anu suii absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. 4[ The systen� has a septic tank and soil absorption system and is.less_ than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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 •. D] SYSTEM FAILS: ':' t 4— I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or,system component due to an overloaded or clogged SAS or cesspool i Discharge or ponding of effluent'to the surface of the ground or surface waters due to an overloaded or clogged SAS or n. I cesspool. , (revised 8/15/95) 2 � }r S `S y 1s2 K ' I I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A I CERTIFICATION (continued) Property Address: 2730 Route 6A Barnstable ,Mass. Owner: Date of Inspection Arlene McCullagh 9/26/95 D) SYSTEM FAILS(continued): 1 Q� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. i { AJ'/j Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. JV Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped i A/ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. & Any portion of a 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 I,of"a public well., I Any portion of a cesspool or privy is within 50 feet of a private water supply well. (� Any'ponion 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.`.If the well has been analyzed to.be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,.ammonia nitrogen and nitrate nitrogen. j E] LARGE SYSTEM FAILS: I The following criteria apply to large systems in addition to the criteria above:' j The design flow of system is 10,000 d or greater (Large System) and the system is a significant threat to public health and safety 1 8 Y gP g g Y Y g P Y and the environment because one or more,of the following conditions exist: i i the system is within 400 feet of a surface drinking water supply i 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 j public water supply wells The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. y. i _ I r I (revised 8/15/95) 3 � z 7 -y.., SUBSURFACE SEWAGE DISPOSAL SYSTEM(INSPECTION FORM i PART B CHECKLIST Property Address: 2730 Route 6A Barnstable,Mass . Owner: Arlene McCullagh Date of Inspection: 9/26/95 Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. I iAs built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up- The system.does not receive non-sanitary or industrial waste flow the site was inspected for signs of breakout. 2II system components,Zkcluding the Soil Absorption System, have been located on the site. Vhe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. l _e/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. i _L/The facility ovmer (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. Recommendations. Ii 1 . Septic tank should,''be pumped." 2. No other repairs ned to be done. i ,, '" „•yam, V. � • r (revised 8/15/95) 4 V + tk • r "'i����Ha ti� tirL�yt. r I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION i Property Address: 2730 Route 6A Barnstable ,Mass Owner:. Arlene McCullagh , .. I Date of Inspection: 9/26/95 FLOW CONDITIONS RESIDENTIAL: a Design flow: jb gallons Number of bedrooms: ` +I Number of current residents: ' Garbage grinder(yes or no):. I Laundry connected to system(yes or no): s , I Seasonal use(yes or no):—U I Water meter readings, if available: — s I Last date of occupancy:&,Cap ed COMMERCIAUINDUSTRIAL° A' J Type of establishment:. Design flow:, allons/day I 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)_ j Water meter readings, if available: ��' Last date of occupancy: Q 1 OTHER: (Describe) r` Last date of occupancy: i GENERAL INFORMATION PUMPING RE ORDS In urce f ofor ation: System pumped as pan of inspection: (yes or WAD If yes, volume pumped. allons I Reason for pumping: TYPE O SYSTEM Septic tank/distribution box/soil absorption system t Single cesspool g Overflow cesspool Privy i Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) i one PROXIMATE GE of all components d to installed (if known) nd s urce 9f' formation: 754/k-Ait 'A f6 7 /e-7— �aP , - ly, eR-r`Cb&dy —� Sewage odors detected when arriving at the site: (yes`or no) _" "V } (revised 8/15/95) S G 9 t s° r i Sewer Permit IIo • Name P Ls•�-� —���->b�� p� ,,• i Installer's .Name and Address i -•.lam-�-� � ., - :� . . Builder's 11ame and Address Date Issued: ate Permi ,t Date Compliance Issued: . 1 �4A t t i • 1 i 600 ��� LCA.4 Jti vC • r -_ :• !,� �� ` .'i.`1•+�i> ` � .. � _ Asa. � ;� y{ 'LYry�+Y•'.4� f�.y� Y w _ ! S f -0,X • TOWN OF BARNSTABLE LOCATION-Z730 i! �.�,., � • SEWAGE #_-T S8 VILLAGE ASSESSOR'S MAP & LOT r y INSTALLER'S NAME. & PHONE SEPTIC TANK CAPACITY. /DDO LEACHING FACILITY:(type) �oDD����/L (size) NO. OF BEDROOMS PRIVATE WELL OR UBLI �WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No . tr, i e � do ile a i •t>L � xc4.�+� 1 • .. E3� CS)C .��� . 'Sr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C t'.SYSTEM INFORMATION (continued) • i • is-_: ,. Property Address: 2730 Route, 6A Barnstable,Mass . Owner: Arlene McCullagh 5 s Date of Inspection: 9/2 6/9 5 SEPTIC TANK:kJA40 . (locate on site plan) r i Depth below grader . Material of construction: Zconcrete _metal _FRP—other(explain) ; t t , Dimensions: Sludge depth: « Distance from top of sludge to bottom of outlet tee or baffle: 04 Scum thickness: Distance from top of scum to top of outlet tee or baffle:_ 4 Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: - (recommendation for pumping, conditi n of inlet and outlet tees or baffles, depth of licWid level in relation to outlet invert, structural�! integrity, evidence of Ieakage, etc.) �D OA/�P zzm-011 VP-4 � iit/�C2t�-s�T�eT Ti�S �?k� 'y .� i �4,U�!! GREASE TRAP:j /� (locate on site plan) Depth below grader Le 1 Material of construction: oncrete _metal _FRP_other(explain) Dimensions: Scum thickness: Distance from top scum to top of outlet tee or baffler Distance from bottom r,t From to bottom of outlet tee or baffle: ' Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural i integrity, evidence of leakage, etc.) 6N (revised 8/15/95) n 4 , SUBSURFACE SEWAGE DISPOSAQSYSTEM INSPECTION FORM PART..0 I SYSTEM INFORMATION (continued) i Property Address: 0 Ro t� �� Btrnstable,Mass . Owner: Mene c u ag Date of Inspection9/26/95 TIGHT OR HOLDING TANK:: • - ' (locate on site plan) • Depth below grade: Material of construction: _concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow:_ gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) I C f. i DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: i Comments: (Z te 'i level and distribu 'w, i; equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) � PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)..AA ¢ F Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/95) 7. t f.. e+s ' 1 SUBSURFACE SEWAGE DISPOSAL,SVSTEM INSPECTION FORM t;` PART C ah SYSTEM INFORMATION (continued) Property Add Route 6A Barnstabl.e,Massi. Owner: Arlene McCullagh r3 Date of Inspection: 9/26/9 5 SOIL ABSORPTION SYSTEM(SAS):1,6611_r- `S R s (locate on site plan, if possible; excavation not required, but n 16y be approximated by non-intrusive methods) If not determined to be present, explain: F Type; leaching pits, number., leaching-chambers, number. . leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number:, ? Comments: (not condition of soil, signs of hydrauli failure, level of ponding, condition of vege tion,etc.) 441 CESSPOOLS: (locate on site tan) 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: / flow (cesspool_must be pumped as-part of inspection) Comments: (note condition of soil, signs of hydraulic'failure, level of ponding, condition of vegetation, etc.) . PRIVY: s4' (locate o s plan) Materials of construdi n:�Q/I/T Dimensions: y Depth of solids: Comments: (note. ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) (revised 6/1s/95) A. e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C` I SYSTEM INFORMATION (continued) Property.Address: Owner: Date of Inspection: s r 4 r SWCH OF SEWAGE DISPOSAL SYSTEM: • a include ties to at least two permanent references landmarks or.benchmarks locate all wells within 100' 0 w � . I X , t 5 f a t DEPTH TO GROUNDWATER r s { Depth to groundwater: feet �'/ f� G , . method of determination or app oximation:_lPiS� h�D.C1L i�it9 f`I�: O /LD GPJl9�� (revised 8/15/95) t 9 = # ' !•ITRTf-Rt7T•'iTSTR�S.R:RiTfIT..I:STMM.V1'if»I:T3TrJSPi'L:.J�ITT'CLZ:TTi�iLT.liS: .. » - ._ T7'�».1STRT�IRT.�••; TOWN OF Rarnstabl a BOARD OF HEALTH SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D •- CERTIFICATION .••t!•t�T•'.•::.�T.Tt>:••.TT.T.t:71'.i.'fSf T3Ti'.SSS'1fSTT.TI:TMT'SIRT3T'RTJT•T.'1TIRT•TlV iil�.TRi.TTTT3 RTRR7.RrRTS40�TTTr1'R:•.TrI'f'T•»t! r -TYPE OR PRINT CI.EARL1'- PROPERTY INSPECTED n t STREET ADDRESS 27•30 R011te hA Barn stablefMass . ASSESSORS MAP, BLOCK AND ?ARCEL # OWNER' s NAME ArI Pnp 060,111 agb f i PART D CERTIFICATION ' I NAME OF INSPECTOR Joseph P.Macomber Jr. , COMPANY NAME J.P.Macomber & Son Inc. r COMPANY ADDRESS lax -h6�'.etervi�lle�Mass 09h32 treet Town or City State LIP COMPANY TELEPHONE 1508 775 - 3338 FAX (508 1 790 - 1578 CERTIFICATION STATEMENT I I certify that I have personally inspected the sewage disposal system at ` this address and that the 1;nf0rmation _reported_ is truel°� accurate,• and complete as of the time of,iinspection . The inspection was performed and any { recommendations regarding upgrade , maintenance , and repair .are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . i Check one: • XXXXX Systeui PASSED The inspection which "I have conducted has not found any information. which indicates that .the system fails to adequately protect public health or- the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated areas stated .in the FAILURE CRITERIA section of this form. . . System FAILED* : . The inspection which J. have conducted has found that the system fails to Protect the public health and the environment in accordance with Title• 5 , 310 CMR 15 . 303, ands as specifically noted on PART; C - FAILURE CRITERIA of this- inspection form . Inspector Signatur Date 2/28/95 j One copy of this certification must be provided to the OWNER, the BUYER ( where applicable) and the DOARD OF HEALTH. * If the inspection FAILED, the owner or . operator shall upgrade ' the ayatetnt within one year of the date.', of the inspection, unless allowed or required ;�` otherwise as provided in 31.0 CMR .15 . 305 . ". ." D tl t t'd-.d n n 1 t C,,,,.,,,cnrvec , IV,Qw4^r• r i Execurve o r� C�VI(Gr',ro^e.^. Depa.rtm end of Environmental 'Protection i ° Water Pollution Connol Tecnnlccl A 5Zicnce ano Training Secnons VAUL&m F.W"d w•.~ Trudy Cosa • I sw.,w.ECfa • I Thomas&Pow•t• • 06/12/95 I ATTN: Joseph P. Macomber, Jr. f,Joseph Macomber and Soil PO Box 66 1 �, Centerville, MA 0263 - Dear Joseph P. Macomber, Jr. , I am-pleased cc inform you chac `:you have attended training, mete j the experience qualifications; and have passed the Title 5 System II Inspector exam, pursuant cu 310 CMK 15.340. . The passing grade for the exam was 39/52 or 75%. 1~° - • This is an official notification that you are a Certified Department - . of Environmental Protection System Inspector pursuant to 310 CMR 15.340. You will receive a System Tnspector certificate at a later date. If you have any fucher questions; please write to me at the following) I address: Kimball Simpson I D.E.P. Training Center 50 Rouce 20 Millbury, .MA 01527. Thank you very much for yoir time and consideration in this matter. Sincerely, _ Kimball . . S:moson, Fr r , k; DEP Training :'• yr Director Vast r2405� Rout. 'n • Millbury, MA . FAX 508-755•v2S3 •. .,n• 508.756-7:°' r. Water . .. '�- __•� Conservation SAVE Tips ME. CHECK FOR LEAKS Water Loss in Gallons Due to Leaks Leak this Loss Per Day Loss Per Month Size • 120 3.600 • 360 10,800 • 693 20,790 • 1,200 36,000 • 1,920 57,600 ,,.,3,096 92,880 ® 4,296 128,980 ® 6.640 199,20Q .6.984 200.520 8,424 252,72-0 .9,888 296,640 11,324 339,720 121720 381,600 . 14,952 448,560 I 0 DATE 5/3/06 PROPERTY ADDRESS 2730 Route 6A unit B Barnstable D0 MA 02630 On the above date, the septic system at the address above was Inspected. This system consists of the following: 1. 1-.1000 ga22on .se12t.ic t¢nk., 2., 1-Di6ta.i&ut.ion lox., 3., 1-1000 gaUorz ieach.ing ' p it., Based on inspection, I certify the following conditions: 4., 7h.iz .is a 7.itie Five ..septic zyetem., (78Code) 5., Septic ay,ztem .is .in paope2 woak.ing oadea at the 12 ent t.imao SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . C~ Address: P. O. Box.66 : Centerville, Mass 02632 <1 �- 7,i — Phone: 508-775-3338 or 508-775-6412 � - n JOSEPH P. MACOMBER & SON,. INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 026.32-0066 775-3338 775.6412 • COMMONWEALTH OF MASSACHUSETTS _. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: 2730 . Route 6A Unit B Barnstable MA 02630 Owner's Name: David Butler Owner's Address: Same Date of Inspection: 5/3/0 6 Name of Inspector: (please print) Robert: A P o.l"in Company Name: % l�acom&e2 ._. S:o.n Lac. 4. Mailing Address: ��,- R' Ce2 eay.c e, a6.6..02632 Telephone Number: 5 0 8-7. 7 5_3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the.sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in.,the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to-Section 15.340 of-Title 5(310 CMR 15A00). The system: Passes -Conditionally Passes s Further Evaluation by the Local Approving Authority it Inspector's Signature: Date: . '3 0 The system inspector shall submit a copy of this inspection report to the-Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system,is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to-the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""Thisreport 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 diffe5ent conditions of use. Title 5 Inspection Form 6/15/2000 page 1 • 1 I Page 2 of 11 OFFICIAL INSPECTIONYORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOB � PART A CERTIFICATION(continued) Property Address: 2730 Route 6A Unit B . Barnstable MA 02630 Owner: David Butler Date of Inspection: 5/3/0 6 Inspection Sum`mary: .Check A B,C,D or.E/AL=AYS,complete all of Section.D A. System Passes: qES NO I have not found any information which indibates'that any of the failure criteria described>in 31-0 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below: Commgnts: SeNt..c aystem iZ .'n pzopelt woaking oadea at .the paezerit tzme.� B. System Conditionally Passes: NO 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 a oved b the Board of Health will ass. P Y P P P P I Ppr ,,.. �,Y. 1 P Answer yes,no or not-determined(Y,N,N .)in the for the following siaiements.If"not determined"please explain. NO The septic tank is metal and.over 30 years old*or the septic tank(whether metal or:not)is structurally unsound,exhibits substantial.infiltration or exfiltration or tank.failura 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: NO 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: NO 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: a 2 Page 3 of 11 OFFICIAL'INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2730 Route 6A Unit B Barnstabie MA Uzbiu Owner: David Butler Date of Inspection: 5/3/0 6 C. Further Evaluation is Required by the Board of Health: NO Conditions exist which require further evaluation.by the Board.of.Health In order to determine.if the system Ts 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: no Cesspool or privy is within 50 feet of a surface water n oo 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 Svppker,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: no The system has a septic tank and.soil absorption system(SAS).and'the SAS is within 100 feet.ofa surface water supply or tributary to a.surface water supply. no The system,has a septic tank and SAS and the SAS is.within a Zone 1 of a public water supply. n o The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. no 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 vizua2 "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: r. 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 27,30 Route ' 6A Unit B Barnstable MA- 02630 Owner: David Butler Date of Inspection: 5/3/0 6 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 X clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or X cesspool _ Liquid depth in-cesspool is less than.6"below invert or available volume is less than%.day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number X of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. _T 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 weil.. Any portion of a cesspool or privy is within 50 feet of a privat6�.water supply well. �. i Any portion of a cesspool orprivy 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 forT..4 NO (.Yes/No)The system fails.I have determined that one or moreiof 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 X the system is within 400 feet of a surface drinking water supply X the system is within.206 feet of a tributary.to a surface drinking water supply X 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2730 Route 6A Unit B Barnstable MA 02630 Owner: David Butler Date of Inspection: 5/3/0 6 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 backup: 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)] 5. Page 6 of 11 OFFICIAL INSPECTION FORM. NOT FOR VOLUNTARY.ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM � PART C SYSTEM INFORMATION Property Address: 2730 Route 6A Unit B Barnstable MA 02630 Owner: David Bit 1 er Date of Inspection: c; / f; FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CNM 15.203(for example: 110 gpd x#of bedrooms). 3 3.0 Number of current residents: 1 Does residence have a garbage grinder(yes or no):ri o. Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no):. rip Seasonal use:(yes or no): .n n Z 0 0 4_7 , 0 0 0 ga 2 o n os P[D:_19 4; 5.Z Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 5=6.4, 0 0 0 ga 2.�o n z q 10[D=17 5 3 4 Sump pump(yes or no): n o Last date of occupancy: 12ae 6 ent COMMERCIALM6- USTRIAL Type of estatas"W hint: N I A Design flow on 310 CMR 15.203): gpd �. Basis of&signifiow(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/user OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 3/17/0:5 12um1 7 mgint Was system pumped as part of the inspection(yes or no):__q e z If yes,volume pumped:10 0 0 gallons--How was quantity pumped determined? m e a s u a e d Reason for pumping: ma.en.t . TYPE OF SYSTEM X Septic tank,distribution box,soil absorption.system _Single cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1983 Were sewage odors detected when arriving at:the site(yes or no): no 6 ' Page 7 of 11 _ OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2730 Route 6A Unit B Barnstable MA 02630 Owner: David Butler Date of Inspection:. 5/3/0 6 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: Z 0 Comments(on condition of joints,venting,evidence of leakage,etc.): o"intz a , Vented thaau h ouze ven SEPTIC TANK:l EAlocate on site plan) 1000 ga-P-Poa.6 Depth below grade: Material of construction:Xconcrete_metal_fiberglass_polyethylene _other(explain) . If tank is metal list age:_ Is age confirmed by a Certificate of Complianet(yes or no):_(attach a copy of certificate) Dimensions: 8.' 6"X5' 8". X4' 10" :'. Sludge depth:_t a a c e Distance from top of sludge to bottom of outlet tee or baffle: to a c e Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: t/Lace Distance from bottom of scum to bottom of outlet tee or baffle: .t as ce How were dimensions determined:. m e a z u a e d Comments(on pumping recommendations,inlet and outlet.tee or baffle condition,structural integrity,liquid.levels' as related to outlet invert,_evidence of.leakage,etc.): R outiet teen ate .in —Pace igiLid eve-P.6 �eae noama-P. o h.ign.6 oO ieakaae. GREASE TRAP: N0(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.): yaeaze taap .i-s not Raezent r 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2730 Route 6A Unit B Barnstable MA 02630 Owner: David Butler Date of lnspection: �5 L310 6 TIGHT or HOLDING TANK: NO(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: 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.): tight oa hoed.in_q tankh a,¢e not Raezent____ DISTRIBUTION BOX:a e s (if present must be opened)(locate on siWplan) . �. 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.): Box .iz has 1 iatezal., No .sotid ca2ayovea oa iekage .in 02 out 0'0 P,ox., PUMP CHAMBER:rz o (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.): PamI2 cham&ea i.6 not /22e ent a Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2730 Route 6A Unit B Barnatabl a MA__02630 Owner: Davi d Riot 1 ar Date of Inspection:. 5 /o r SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located see 12age 10., Type X leaching pits,number: 1 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition.of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): ., Loamy. to medium .sand. .No zignz 0P �ai�une kO2 pondina. SoiP.s ate 32yo Vegetation' .is no zmdi CESSPOOLS: N0 (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.): Ce.6s/2oo.P.6 ate not /22ezeat., PRIVY: NO (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): /)aivy 1.6 not 121teseat ,a 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued)` Property Address: 2730 Route 6A Unit B Barnstable MA 02630 Owner: - David Butler Date of Inspection: 5/3/0 6 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. . / �" �l . . 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2730 Route FA unit. B Barnstable MA 02630 Owner: David Butler Date of Inspection: 5/3/0 6 SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to ground water.D feet ` Please indicate(check)all methods used to determine the high ground water elevation: -NO Obtained from system design plans on record-If checked,date of design plan reviewed: y e s Observed site(abutting.property/observation hole within 150 feet of SAS) �Checked with local-Board:of Health-explain:ry u,� 0 f o n-n d no Checked:with local excavators,installers-(attach documentation) Accessed USGSdatabase=explahiAt-fP:t own. kaanz tag ie,,,ma. u!s You must describe how you established the high ground water elevation: 11.sed. : Cape Cod Commis-ion ldatea 7agiz Coritouas And %ugtic blatea Sup/:.By lde2 Ta .2 head otecTion aaeaz map.- Sept 1995 Watea aehouaces o4-lice cane cod commi.6ion , Leaching Pit IQ . feet GroundwaterWfeet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method _14 . Therefore,the vertical-separation distance between the bottom of the leaching pit and the adjusted groundwater table is�•�, j1 feet: �J ll TOWN OF BARNSTABLE BOARD QF 11$A•LTH ,9UDSURFACK SEWAGE DISPOSAL SYSTEM:INSPECTION FORM - PART D CERTIFICATION -TYPI 01 PRINT OI,UM- PRQPERTY INSPFCTHV STREET ADDRESS 2730 Route 6A Unit B„ Bgjrngtabj_ Q2610 �...:. A•SS•ESSORS MAP, BLOCK AND 'PARCEL OWNER'S NAME David But er , PART`D OHRTIFICATrTON NAME 'OF INSPECTOR RoAe.tt Pa.o:Un.i o ae h :P.� llaco►ni� ' Son Inc COMPANY NAME III, 13ox 66 " -Cen40_,%V . " Oaz,6' .02632 ' COh1PANY ApD.g.��S. ' Str. 1' Town-or 01y. » 8ta • LIP COMPANY TELEPHONE ( 508. Y�7.5 - 3338 -PAX , ('.508',:1V'90 f578 CERTIFICATION. STATEMENT I certify that. I have persotiallly .inspected .the sewage digpoxal. system at this address and that. :t6d' information reported .is true,. aoofAra•te•, and omplete as of the time of••inspeetiony The inspection was per•Forined and any recommendations regarding upgrade•, .ma•intenalncel, abd repair •are• eongis'tent with my trainip,9 and expgrience in th8 ppoper futTotion' and maintenance of on-- site sewage disposal syste.me. Check one: Systeci PASD . The inspection whic.M •.I. have .•eonduoted has .,n•ct' found any information . which indicate$ that. the system- fails to ' adequately. p.rotect .publi•a health or the envi.ropment as defined in' .310 CMR. 15' 30.3', 'Any failure criteria 00"t -•evaluafid are as stated in the FAI-LURE CRI-TM ,IA .section of this, form. System FAILED* The inspection which I have c�nm­ted *has found that the System fails to protect the public health snd the enVArorrmen•t ' in acgatdance with Title 51 310 CMR 15 . 3031 and as - specifically noted -on .PART' C FAILURE CRITERIA of this inspect n•.form, Inspector Signature' Dat9 ne' copy of this certi,f ioat•l:ah''must •b0rcvided *to t the •QWNLY�•, t��e BUYER where appli:aable) and the DPARD OV HSA Ttr : ' * if the inepeot$on FAIL•Ep•j the .owns'b'.Ox �9Fesatos -G:hal,t - upg•rade •the eyetem• within one year of the da't•e of the inspection, unless. a];'lowsa Qri * req k ,red n r.hprm{se as provided iri gj10 CMR 15 ,3061. , DATE: 9„/'28)95 PROPERTY , ADDRESS:_;2730A'.Small House. Route.- ,6A Barnst,�b16' Mass 02630' On .the above date, I. Inspected the septic system at the above address. This system consists of the following: Y 1 1 l000 gallon septic tank. 2. 1--Distribution box. 3. 1=1000 gallon leaching: pit. Based bn my Ins;*ction, i certify the following coed"ltlons: 1 This is- a title five septic, system.. ( 78 Code 2�.- The,> gjeptic'• system As .in•, proper working order-t- at 'the- present time. 9IGNATUR!7 I Name: J_P_M_acomber Jr.. ! `�•P_MacorQber_ &. Son_Inc. Company:_ 'a -- . Address:_-B,e.c-bb-----=1--- — Centerville LMas_s • '0.2.632 ' Oar1995 4 Phone: one:---508 7.5�.3338_��_ t. unrA THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY ' JOSEPH P. MACOMBER & SON,. INC. Tanks-Coupools-Leachffeld: pum pad Inatslled ° Town Sewer Connection: m I P.O. Box 6V Centerville, MA 02632.0066 77-5.3338 775-6412 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Go✓emor Trudy Coxe Secretary,EOEA ' David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f " PART A CERTIFICATION Property Address: 2730A Route 6A Barnstable Address of Owner: Date of Inspection: 9.26.95 (If different) Name of Inspector: Joseph P.Maco ber Jr. . Company Name, Address and Telephone Number: 4 t i , CERTIFICATION STATEMENT I cert4 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 inspection. The inspection was performed based on my training and experience in.the proper function and maintenance of on-site sewage disposal systems. The system: - asses r _ Conditionally Passes _ Needs Further Evaluation By,the Local Approving Authority _ Fails g- Inspector's Signature /, � Date: g^ t The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection: The original should be sent to the wStein owner and copies sent to the buyer, if applicable and the approving authority. ; INSPECTION SUMMARY: - - Check A, B, C, or D: A] SYSTEM PASSES: --IL l have not found any information which indicates that'the system violates any of the failure criteria as defined in 310 CMR 15.303 Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: i One or more system components need to be replaced or repaired. The system, upon completion of the'replacement or repair, Passes inspection: Indicate yes, no, or not determined (Y, N, or ND).`Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as °- approved by the Board of Health. " a .(revised 8/15/95) .14 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • h�Telephone(617)292-5500 � i SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2730A Route 6A Barnstable,Mass . Owner: Arlene McCallagh Date of Inspection: 9/2 6/9 5 B) SYSTEM CONDITIONALLY PASSES (continued) , • Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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. 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: jZ Cesspool or privy is within 50 feet of a surface water ,Al 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: A/ The syscem nas a Septic tank anu will absorption systen-, and.is within 100 feet to a surface v.ater supply or tributary to a surface water supply. ,Z The system has a septic tank and soil absorption system and is-within a Zone I of a_public water supply well. 4,, The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or,more from a private water supply well, unless a well water analysis 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. D) SYSTEM FAILS: ' I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Al Backup of sewage into facility or.system component due to an 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. (revised 8/15/95) 2 5 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) r Property Address: 2730A Route 6A Barnstable ,Mass . Owner: Arlene McCallagh Date of Inspection: 9/26/95 D) SYSTEM FAILS (continued): • • AZ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. l Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.': Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Al Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Ale Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Al— Any portion of a cesspool or privy is within a Zone I of.a public well. f' i A' Any portion of a cesspool or privy is within 50 feet of a private water supply well. 4_1' 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: / The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety y and the environment because one or more of the following conditions exist: , 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/i5/95) 3. s a 4 r - ._.ri } `d I �j I � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2730A Route 6A Barnstable,Mass . Owner: Arlene McCallagh Date of Inspection: 9/2 6/9 5 Check if the following have been done: ,Pumping information was requested of the owner, occupant, and Board of Health. one of the sy tem components have been pumped for at least two weeks and the system has been receiving normal flow rates during that pellod. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. Zhe system does not receive non-sanitary or industrial waste flow _L/The site was inspected for signs of breakout. 11 system components, okcluding the.Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 4/hie size and location of the Soil Absorption System on the site has been determined based on existing'information or approximated by non-intrusive methods. Zheacility ov,ne: (and occupants, if different from owner) were,.provided with information.on the proper maintenance of Sub- Surface Disposal System. •Re'commendations 1 . Septic tank must be pumped. 2. No other repairs needed at this time. Af . . (revised 8/15/951 4 S- if`• .sy �I.S r. L• SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION . Property Address: 2730A. Route 6A Barnstable,Mass . Owner. Arlene McCallagh Date of Inspection: 9 2 6 9 5 FLOW CONDITIONS , RESIDENTIAL: Design flow: XW allons Number of bedrooms: 02 Number of current residents: Garbage grinder(yes or no):AA Laundry connected to system (yes or no):-kD Seasonal use (yes or no):_AIj) a Water meter readings, if available: '' Last date of occupancy:J��[" COMMERCIAUINDUSTRIAL• Type of establishment- Design flow:_ gallons/day Grease trap present: (yes or no) if! Industrial Waste Holding Tank present: (yes or no), Non-sanitary waste discharged to the Title 5 system: (yes or no)AO Water meter readings, if available: Al Last date of occupancy: OTHER: (Describe) y� Last date of occupancy: GENERAL INFORMATION K PUMPING RECO DS andsurce of i formation: t�r System pumped as part of inspection: (yes or no If yes, volume pumped. allons Reason for pumping: /4141 11),4 964 TYPE O YSTEM Septic tank/distribution box/soil absorption system XSingle cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) AjPROXIMATk AGE of all components, date installed (if known) and source of information: aw-4L S lankiwA, 6h ' Sewage odors detected when arriving at the site: (yes or no) ♦ r�� t (revised 6/15/95) Sewer.Permit IJo• �f hocation..A 7z-Q — -- Installer's Name and Address � `�. A1flA"T� 1�ff Builder's Name and Address �0]'� Date Permit Issued: •. . :,Date Compliance Issued: { ✓ i•er � •�w�151�.'�.�1(1 ;ttl ! ��` / y �`� Y�`/'tL �:�.., ,,��i, � -� -!W" 'r •. � _;...,�', r 4iK' •.i r �� r a „�i,•pv SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C... SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK:106D (locate on site plan) Depth below grade: Material of construction: J::�concrete._metal FRP_other(explain). ° Dimensions: Ai" Tt HOA Al ip 11 WIVIt, Sludge depth: L Distance from top o fsludge to bottom of outlet tee or baffle: 3� Scum thickness: Distance from top of scum to top of outlet tee or baffle:3 ct Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, conditi n of inlet and outlet tees or baffles, depth of liquid level'in re l Lion to outlet invert, structural integrity, evidence of leakage, etc.) l' l c( � t GREASE TRAP: (locate on site pan) Depth below grader Material of constr ctfon concrete _metal _FRP_other(explain) Dimensions: AY110. // Scum thickness: Distance from top f scum to top of outlet tee or baffle: Distance from bottom of <<um to bottom of outlet tee or baffle: , Comments: ! (recommendation for pumping, conditi,,o� of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) i r .Izevised 6/15/95) 6 *"s 4 1 y SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2730A Route 6A Barnstable ,Muss. Owner: Ar;ene .McClullagh,. Date of Inspection: 9/2 6/9 5 TIGHT OR HOLDING TANK: e (locate on site plan) h Depth below grade: Material of constructi n4concrete_metal_FRP_other(explain) Dimensions: - i Capacity: rallons Design flow: Aa allons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet invert:.N _ Comments: (note if�evel and distributiul, i, equal, evidence of solids carry ver, evidence of leakage into or out of box, (b ou 4.1 r • f PUMP.CHAMBER: I� (locate on site plan) Pumps in working order:(yes or no) J Comments: (note dition of pump chamber, condition of pumps and appurtenances, etc.) 2 I. i (revised 6/15/95) 7 L r. fr a M I SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM _. PART C - SYSTEM INFORMATION (continued) I Property Address: 2730A Route 6A Barnstable,Mass. Owner: Arlene McCullagh Date of Inspection: 9/2 6/9 5 SOIL ABSORPTION SYSTEM(SAS): , (locate on site plan, if possible; excavation not required, but�may be approximated by non-intrusive methods) If not determined to be present, explain: i i i Type; ' p leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition f soil, signs of hydraulic failure, level of pondi% condition of vegetation,etc.) ,(1 I CESSPOOLS: (locate on site Ian) Number and configuration: r 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 (cesspool must be pumped as part of inspection) Corr nts: (note condition of soil, signs of hydraulic'failure, level of ponding, condition of vegetation, etc.) O - i PRIVY:k (locate plan) Materials of constructi n: �� Dimensions:_ Depth of solids: ' Commen : (note condition of soil, signs of hydraulic,failure, level of ponding, condition of vegetation, etc.) t } (revised 8/15/95) B � r'd� o • h to ay�� � r;,' • if I Y. A:F' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 7 3 0 A , Route 6A Barnstable ,Mass . Owner: Arlene McCullagh . Date of Inspection: 9 2 6 9 5 1 i Shish OF SEWAGE DISPOSAL SYSTEM. • include ties to at least two permanent references landmarks or.benchmarks i locate all wells within 100' La'.V 9 -.t IV L r • / F i r i . 1 . _ `lam`' • DEPTH TO GROUNDWATER 'y , Depth to groundwater: / f feet _ a—e method of d�ermination or approximation: v ti S/ 1 (revised 8/15/95) 9 � t p .•tiF' j zi M1 j�. s •m+nr+re—rserr•-.-r-:rnrm::r.r..rmsrrnrrrr.::•r-r.:�sen�+rranesntse--rsrar�rsressa .rsrrrr-.trrmr-�mr.r•-F '1'UWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE, DISPOSAL SYSTPH INSPECTION FORM - PART D - CERTIFICATION � h•••se•f-r•:-::r-rar.-.-T.r.r.•m•er:ms•-jar.-s+trre�ern'rz•rri.�zrmarTn•nTnn-rrrr�xssae•.sr+a+nrxin�sarzsassm.s'rmrnre�nrrrTrrsr..-rrrr r. �r -TYPE OR PAIHT CI.EARLY- i PROPERTY INSPECTED STREET ADDRESS 2730A Route 0a Barnstable.Mass. ASSESSORS MAP, BLOCK ANI� PARCEL # OWNER' s NAME Arlene Mceullagh PART' D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr. . COMPANY NAME T_P_Macomher & Son Inc. j COMPANY ADDRESS Box 66 'Centerville,Mass. 02632 Street Town or City_ State LIP { . COMPANY TELEPHONE ( ) FAX ( ) 08 77 3338 508 790 - 1578 CERTIFICATION STATEMENT p 4 I certify that I have personally inspected the sewage disposa-1 system at this address and that the information. reported is true , . accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent- with my training and experience. in the proper function and maintenance of on- site sewage disposal systems . Check one: XXXXX System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 ._ Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILEll* The inspection which I have conducted has found that the system fails to protect the public he.altli and the environment in Accordance with Title .5 , 3.10 CMR 15 . 303, and as specifically noted on .PART C',- FAILURE CRITERIA 'of' this - inspection form . Inspector Signature Date 9/28/95 One copy of this ert.ification must be provided to the OWNER, the IIUYER '' ' a '... ( Where applicable ) and the DOARD OP' HEALTH. Xfl If the inspection FAILED, the owner or operator shall upgrade ' the ey8telii "^� i within one ' year of .the date of the inspection, , unless allowed or required": : { otherwise as provided in 310 CMR 15 . 305 . - '4a, _ C=mcnwec^^ c, ivlasscc^- `stirs ' EXerCIllNe Ot iC. or Envlrcrmenic: Department of Environmental Protection Water Pollution Ccntrol Tecnnlccl Assocnce ana Training Secnons W181am F.WOW Trudy Cox Se=wmy.COCA Thomas 8.PowKs 06/.12/95 ATTN: Joseph P. Macomber, Jr.-. Joseph Macomber and Suit PO Box 66 n Centerville, MA 0263 - Dear Joseph P. Macomber, Jr. , T I am pleased to inform you chat.,you have attended training, met the experience qualifications, and have passed the Title 5 System Inspector exam, pursuant to 310 CMk. 15. 340 . The passing grade for ,. , the exam was 39/52 or 75�. This is an official notification -that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340. You will receive a System Inspector certificate at a. later date. If you have any. futher questions, please write to at the following address: Kimball Simpson 1).E. P. Training Center 50 Route 20 Millbury, MA-., 01527 Thank you very much for yoj`c time and consideratiol: in this matter. Sincerely, Kimba11 T. S:moson, DEP Training - or Director 22405 Route ..t • Millbury, MA • FAX 5G- .755-V2SJ • in• 508-756-7^°• { �5% - i H i �. • 1 r\^ Y Water'. Coris'erva_ ton SAVE Tips , ME! ;..C,HECK FOR LEAKS Water Loss in-Gallons Due to Leaks Leak this Loss Per Day Was Per Month Size " 120 3.600 i s • 360 10,800 • 693 20,790 • 1,200. 36.000 • ':1.920 57,600 I` 3,096 82,880 .0 4,296 `128,980 ® 6.640 199,200. !.0,984 200,520 8,424 252,720 9,888 296,640 ® 1:1.324 339,720 1.2-720 - 381.600 14,952 "448,560 • ` ,a t LDS i ASSESSORS MAP : P cE� : z TEST HOLE LOGS OW AR NOTES: ` iC�/ C SOIL EVALUATOR FLOOD ZONES ...__.. _G�.._...�k'61 L WITNESS : v{. REFERENCE: -tj / 77��1 ,9��R��� "' L,rC�, _ DATE: Ulm 1 ' t l 1) The installation shall comply with Title V and Town of Barnstable Board of ^-- - ' -( T E: ..� Z ICI M-Ei I Health Regulations. f PERCOLATION RA �,q) ____. 2) The installer shall verify the location of utilities, sewer inverts and septic ' 1640 4/ w _ components prior to installation and setting base elevations. TH- 1 TH-2 _ 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first two feet out of the d-box to the leaching shall be level. 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. 5) `All septic components must meet Title V specifications. 6 Parkin shall not be constructed over H10 septic components. LOCATION MAP ; a � ) g p P 7) The property is bounded by property corners and property lines. p �z 8) The property owner shall review design considerations to approve of total ' �3 '� � � � design flow and number of bedrooms to be considered for design. Receipt 3Z,nc) of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. fi /�� 9) The existing leaching or cesspools shall be pumped and filled with material O t �� a alb 44,4)mv� �' per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the -, SEPT i C SYSTEM DES I G N water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service n line. The line is to be sleeved as aforementioned and maintained in place. -- FLOW ESTIMATE MATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. 3 BEDR00'MS AT 110 GAL/DAY/BEDROOM •��" GAL/DAY 12)The installer is to take caution in excavation around the gas line if such � l exists. \SEPT I C TANK 13 The installer shall verify the location quantity and elevation of the sewer lines exiting the dwelling prior to the installation. '3AL/DAY x 2 DA S - GAL USE =GALLON SE TIC TANK (1�f N SO i L ABSOV11I-0m 1W LIWNLApt2W e OF DAVID � MASON m No.1066 f - C� �8 SEPT S S� EP I C Y TEM, SECT I ON `7 QO L - ' ( -x vy k44 t D o �. �-y^Wy-� 33Z o -, V � D i GAL 371, Q . SEPTIC TANK :. r t 02 70 7 7?. Y S I T E AND SEWAGE PLAN a F'ec 70.--_ -=------- f LOCATION : � PREPARED F 0 R rT- ol — i SCALE: DAV I D B . MASON;R---- DATE: ---' ` DBC ENVIRONMENTAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA