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Home My WebLink About3517 MAIN ST./RTE 6A(BARN.) - Health 3517 MAIN ST./RT. 6A,BARNSTABLE A= 090 232 o �n r. P v � 4 v a go No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Complete System . ❑Individual Components Location Address or Lot No. "3 517 Mu w 5 t R 1—64 Owner's Name,Address,and Tel.No. 'bAr�5iu�1� .'� -1 Assessor's Map/Parcel 'a i.•-) �S_ �J�ICJ Maer Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. t `3cvw.-4 i=,�c s�r�2v�Y�3�1 >5,15Oe eevvs LJO✓I(% Type of Building: Dwelling No.of Bedrooms 3 Lot Size R 1,3C sq.ft. Garbage Grinder( ) Other Type of Building r e b ic)e o !C A No.of Persons 7- Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3() gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title 1 Size of Septic Tank C)C i 5fikv c Type of S.A.S. (OWS e7t C� �n irk 1 V t IKG,h-)(-� Q Description of Soil Nature of Repairs or Alterations(Answer when applicable) l,N �Gkk L t►o 1n I i N t 1- &} >Z r9N JJ�G✓� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe _ Date Application Approved by I AADate ��_(k Application Disapproved by Date for the following reasons Permit No. ;o r O 3 Date Issued 0_5 Fee • computer: � «� • THE COMMONWEALTH OF MASSACHUSETTS Entered in c j PUBLIC HEALTHDIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes �s •• ,=rat �MppltLAtion for Zisposal �pstrm �OIIB ULtIOTY PrITCtt A plication for a Permit to Construct( ) Repair(t` Upgrade( Abandon( ) ❑Complete System ❑Individual Components' '. ' I ocation`Address or Lot No.;3 717 MG an+51Z4 Owner's Name,Address,and Tel.No. t Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. '��sl�-s � '`'aeov3N Sac sOfj-�O�faw�`/Ss3�/ �^��wz'tor'rv�j Wr,✓4C5 Type of Building: Dwelling No.of Bedrooms Lot Size R13M sq.ft. Garbage Grinder( ) Other Type of Building C)e�,*kCA\ No.of Persons Showers( ) Cafeteria( ) = Other Fixtures Design Flow(min.required) 3'30 gpd Design flow provided 351 ;Z.; gpd Plan Date lr'1 Number of sheets Revision Date Title _ Size of Septic Tank. CX 1 t�1 S Type of S.A.S. •G ((Xit, o� C. ,n tfaO 1A1 %IEfab(*h 2 C) Description of Soil y Nature of Repairs or Alterations(Answer when applicable) t )StGt, G vouaS 0 G ti, ' to 1N t ll vfc.lOf LA-?O UN��-f, G S S�tOW N C9ry ,(J�C✓�1 - a •r Date last inspected: 1 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed .!�,- ----- ` Date Application Approved by �✓C- w + j2- J DateYJT' Application Disapproved by Date for the following reasons y � / }Permit No. 6 013 Date Issued 3 - ---------- --•--•-•--- - -•----- - --- - - - - ----------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned( )by S::�oOGs A Cx.t)N'1 CJ C.- at b S l'7-MG ail $1- V_+ C. I_-,(Pb��)C has been constructed in accordance with the provisions of TitleAA 5 and the for Disposal System Construction Permit No. dated Installer ^ (0A.tk11 TNL Designer �/�,I��'�'✓{N• 14�ylrs #bedrooms 'lj Approved design flow '��aU gpd The issuance of this permit shall not be construed as a guarantee that the syste will fu c io as�I�i)gned:r �'`' Date /I 2� Inspector\ ./ �......»- - w_ _. . -- -------------- ----- ---------------------------------------- ------------------- No. g619 5?3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS r Misposal Opstem Construction ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( 1I) Abandon( ) o / System located at 3 !n-7 � r,„j �'=, F- /2 it t✓4 �1�1?4 "s/-,y��-e o 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. ; Provided:Construction must be completed within three years of the date of this permit. Date ?2 ( p Approved by • Town of Barnstable °pIME ram, Regulatory Services ti Richard V. Scali, Interim Director ' BARNSTABLE, Public Health Division MASS. 4'Al'639 a�• Thomas McKean, Director fp MA'S 260 Main-Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Systems Property Address: ��'.�1 2 / cRt cSi', �� e 6A Assessor's Map\Parcel: —L 1 7 —O G-5— l�1 Property Owners Name: UW4.rz� 411 L)4 d rIlk (:X In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an "x" in the applicable box next to each line certifying the information. Yes N\A 9 ❑ I have been provided a copy of the Title 5 I/A technology Approval letters. (15 page Standard Conditions letter and the specific technology letter) ❑ I have been provided with the Owner's Manual ❑ I have been provided with the Operation and Maintenance Manual ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(l0) and the Approval ❑ 9 For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) ❑ If the design does not provide for the use of garbage grinders, the restriction is understood and accepted bZ ❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the dirLd er ines he System to be failing to protect public health and safety and the , e , as efined in 310 CMR 15.303 .4 agree to comply with all terms and conditions above_. =nekkkprinnted name Property Owners Signature Date Note: This form must be submitted along with the septic system disposal works permit j application for all I\A systems including new construction, repairs\upgrades, with and without aggregate (stone) and with conventional design criteria or credited design criteria. Q:\Septic\IA homeowner certification.doc Town of Barnstable �oF'T KME ,o y� Regulatory Services Richard V. Seali' Interim"Director BARN SfABLE MAC Public Health Division Thomas McKean,Director 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Fax: 508-79076304 Installer&Designer Certification Form Date: -7 t6 k Sewage.Pei•mit# 4,- 0(R s--O:Z- Assessor's Map\Parcel jl-7—Oo-57 Designers oce�,n! Wo -bts,. (nc Installer: i �4 , �.ra n " p Address: IZ W, Cebssl—/� te W Rd Address: 16 Ejx \ A 0 Z(:4 y Ce.� �,e-ram�l`� Z�3Z �� " C was issued aPerm, to install a On�-�2=1� (d a " "installer) septic system at based on a design drawn by e a-e i, Mc E.�+tee , L (address) COO f�ti ��C , dated 1 �;.I .``.� J� � l �C r✓lit�i/tex��itc ti� • (designer) I certify that the septic system referenced above was installed substantiallyaccording.to the design, which may include minor approved changes'such as lateral relocation of the distribution box and7or..septic tank: .Strip out (if required) was inspected and ;the soils were found satisfactory. I certify that the septic system referenced above.wa s.installed'with major changes (:i:( . greater than 110' lateral relocation of the'SAS or any vertical relocation of any component • of the septic system) but in'accordance With State & Local Regulations- Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and,the soils were found satisfactory I certify.that the system referenced above was 'construet( " nce:with.the terms of the I\A approval letters (if applicable) "OF ART r+*wrEe CIVIL, Installer's Signature) +vo.35t� RFQI8TfRti ` (Designer's Signature) (Affix Designer tamp Here) PLEASE RETURN TO .BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED` UNTIL BOTH THIS FORM AND. A S BUILT CARD ARE RECEIVED BY THE;BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Dcsiencr Certification Form Rev 8-14-1Idoc 4� TOWN OF BARNSTABLE LOCATION 3S, 17 R'� G� �� S�' SEWAGE# Otg ®']S VILLAGE-t-�6,d,�r, ,}P ASSESSOR'S MAP&PARCEL31 INSTALLER'S NAME&PHONE NO.Zb� - SEPTIC TANK CAPACITY C'`►:[S'�-I N LEACHING FACILITY:(type) k sk' 1 yfC4y15 (size) 1-7 )( 1 7,C NO. OF BEDROOMS OWNER C j fCc Q7 C) PERMIT DATE: `Z,—`2 2 -) COMPLIANCE DATE: -7 -l Separation Distance Between the: �"'(JC' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility P,'J CtVNh'`? 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�Z'r"K x)t'� Iy _1_G 6C�rs1�l� q ' A i3 Town of Barnstable r# Department of Regulatory Servic..es. ;( auuver►ar g Public HeAlth Division Date ' 200 Main,Stieet,Hyannis MAa)2601, y Date'Scheduled r� Ttrrie Fee Pd. Cl A. C'J'e1 Soil,Su tak lity Assessment;f ar ,Sewcz e D�* posala Performed Ry: � S ZVJitnessed By:... LOCATION&.GENERAL INFORMATION [oration Address 7 Sfi&),e6I) Owner's Name a ✓t q�y Cb dYi-S 6i K AAddress. d` p-3;0 l� syli IVI/� 112J Assessor's Map/Parcel:, `— `?j f'��- Engineer's Name NEW CONSTRUCTION RBPAIR Telephone# g'—4"71:�-5- C r 73 Land Use Res 0,--VI jr- al p SiiTface Stone Slopes —16 f -C . s Distances:from: Open Water Body 7JUd ft Possible Wet Areal tro.. ft: Drintring'Water We11'7> Drainage Way N.1IA- ft Property.Line ft Other t ft. SKETCH:(Streername,dime i*n of lot,exact locations of test;holes&perc tests,locate wetlands(n proximity to holes) ,i P,,j LQ C Lq Parent.material(geologic) /'w✓gl✓tlL Depth to Bedrock. /vow Depth to Groundwater. Standing Water in i-lol,c- I�Je (,r�LAJ Weeping:from Pit Fipe. Nd(\�L Estimated'Seasonal.High,Groundwater DETERMINATION FOR SEASONAL HIGH WATER TAUS,. Method Used: I Depth Observed standing in obs,hole: in: Depth 10 soU mottles: Depth to weeping from side of offs:hole: in, arotindwater AdJusttitent ft , Index Well# Reading Date: index'Well level R a,,.„ Ad.l.factor, AdJ;f)routittwater Ldvei.„,, p P.9RCOL<ATION TEST bate Time ° : Observation DIX io �Q k e�+� )�t wl,ie Hole# > Time a9l' _ tNa.5 f ke ^'t �' Zlt mod'- Z Depth of Pere _ r Time ai 6" Start Pre-soak Time End Pre-soaker Rafe:M n:/Inchcr�Mf14Clad �✓t y=tw4L�'� . / 6 J"e `t.(� e Site SuitabilityAssessment: Site Passed Site Failed: Additional Testing Needed(YM) Original: Public Health Division Observation Hole Data.To.Be.Completed on>Back----------- ***If.percolation test.is'ao;he-conducted within:100'of wetland,you must firstmotify the Barnstable Conservation Division at Least one(1)week prior.-to beginning. Qi4SEPTICIPERCFOR ,DOC , DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling '(Structure,Stones,Boulders. o sigengy,% ravel -, 2 g ` ,-�dy {aqt�, Iti-3� S-%4j 9agwl 16.1 (,, `16 Cam . z,sY 4,A DEEP OBSERRVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mun'sell): Mottling (Structure,Stones,:Bouidets. Comis tcncy.% 'rave �vvrA Lapp-` to `t'✓Z-yf z i2-�6 f3 lcl4w► a Y�310 36,--77- G j JJ, 160,014 la`�YZ _7Z - IZa Ci C6q�` �grtit DEEP OBSERVATION HOLE LOGS Hole# Depth from. Soil Horizon Soil Texture Soil Color Soil Other Surface Ou.) (USDA) (Munscll) Mottling (Structure,Stones,Boulders:. Consistency, Q e DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil,Color Soil Other Surface(in j (USDA) (Munsei.l) Mottling (Structure,Stones,Boulders. on"i ten ° I Flood Insurance Rate Map: Above 500 year floo&boundary No— Yes Within.500:year boundary. No Yes Within IGO year flood boundary No.,&- Yes,,... Depth of Naturally Occurring Pervious lYlaterial Does at least four feet of naturally occurring pervious matorial exist in all areas observed throughout the area proposed for the soil absorption systeml `f e 5 If not,what is the.depth of naturally.occurring pervious mairrral7 Certification I certify that on 1 l l Q 4 `(dated I have passed the soil evaluator examinat on.approved by the. Department,of Environmental Protection and that the above analysis was performed by me consistent with the required tr ng,expertise and experience described in 3i0 CMR 15.01'7.. � � Signature, Date----t--"— QASAPTj0pFRCFORM,.DOC I _- s TerroFilter,LLC. P.O.Box 227 10 Main St. e'9ft� Sturbridge,MA 01566 Tel: (508)347.5508 TerraFuter (877)347-7263 Fax:(508)347-9857 February 6, 2018 Peter McEntee Engineering Works, Inc. 12 W. Crossfield Rd Forestdale, MA 02644 RE: Particle Size Analysis(Alternative to Perc Test) 3517 Main Street, Barnstable,MA 02630 Dear Peter; Below are the results of the particle size analysis from the sample submitted for the above referenced property. The analysis was performed utilizing the hydrometer method of Gee & Bauder (1986) in Methods of Soil Analysis, Part 1. Physical and Mineralogical Methods, 2nd Edition. Sand Silt Clay (2.00 to.05mm) (.05 to.002mm) (<.002mm) Portion Passing 75.2% 18.9% 5.9% #10 Sieve USDA Soil Textural Classification: Loamy Sand MA Section 15.243 Soil Classification: Class 1, Based upon the DEP's Title 5 Alternative to Percolation Testing Policy for System Upgrades, the-following = effluent loading rates apply: Un-compacted Soil 0.66gpolsf Ati-Qrk Should you need additional information, or require further testing services, please do not hesitate to contact our office. Sincerely, Mark Farrell, Soil Scientist F Engineering Works, Inc. Civil Engineers-Surveyors-Soil Evaluators 12 West Crossfield Road; Forestdale,, MA 02644 Tel/fax (508)47.7-5313 s , Re 3517 Main Street (Route 6A), Barnstable Soil evaluation 1/24/1.8 Ref. P-1515178: Engineers note: The results of the sieve analysis performed on._soils obtained.from the ".C2" soil horizon indicate the texture bordering on.the loamy sand/sandy loam boundary. The soils observed at the time of the soil evaluation within the C2" horizons of both TO 1 and,TP 2 appeared to be more;consistant with textual Class II, sandy loam soils. For"this reason, as the Certified soil evaluator conducting evaluation, ,I-am classifying the,soils within the "C2 horizon to.be:uncompacted.Class II soils with a Effluent Loading Rate of, 0.33 GPD/SF. 0 3 Peter T_. McEntee PE, CE #1542 100 90 . ` o ;80 ry� fi0 tay' j �`o silty 40 sari cl V-Xy O ` iy to cl ^. 30 san cla ` 0 2 10 san ,`jloa sl fg a silt san. sa d10, O O `cO. O percent sand Soil Textural Triangle Commonwealth of Massachusetts :.; Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE MA 02630 OCTOBER 29,2012 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 ti' to move your MARK L WHITE cursor-do not Name of Inspector r.'x use the return -4 - v �. key. NEIGHBORHOOD WASTEWATER ' Company Name I, .) , r 350 RT 28 Com an Address .. ,�;"a WEST YARMOUTH MA r,y r� City/Town State 02673,, - Zip Cod4 508-775-2820 S113381 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.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: AIA Passes Conditionally Passes Fails.,�N�` p��N QFS' '��i,,�� Needs Further Evaluation by the,Local Approving Authority MARK ''yams WHITE o; *. No.S13381 42 OCTOBER 29, 2012. $!�TIFn�O�o��.` Inspector's Signature Date ��ii4/ftrmtruu�►��`� „The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP),wlthin 30 days of completing this inspection. If the system is a shared system or has a design floW6fAbl,C04) 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. ****Thtssre�poit;on;I- do criA q conditions at the time of inspection and under the conditions of use b., at that time. This inspection does not address how the system will perform in the future under thoisame:or. diffe e t eQQ ditions of use. 3aS.�iliivo JU �i'':V r I �tdl l 1 t� t5ms•11/10 Title 5 is I Inspection Form:Sub race Sewage Disposal System•Page 1 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments > 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name everypage. BARNSTABLE MA' 02630 OCTOBER 29,2012 ry9 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:. Check A,B,C,D or E L always complete all of Section D A) System Passes: ❑x 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 th*e.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 p N ❑ ND(Explain below):. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for BARNSTABLE every page. MA 02630 OCTOBER 29,2012 Citylrown State Zip.Code. Date of Inspection B. Certification (cont.) 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 T❑ Y ❑ N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s).are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed. E Y . , ❑ N ❑ ND (Explain below): 5 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 20 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE MA 02630 OCTOBER 29,2012 Cityrrown State Zip Code. Date of Inspection 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 B. Certification (cont:) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in.a manner that protects the public health, safety and environment: ❑ The system has'a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal ` coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for gARNSTABLE - MA 02630 OCTOBER 29,2012 every page. Cityrrown State Zip Code Date of Inspection 3. Other: 1 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 ❑ ❑x 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 %day flow B. Certification (cont.) Yes No 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x Any portion of the SAS, cesspool or privy is below high.ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or El 0 tributary to a surface water supply. 0 0 Any portion of a cesspool or privy is within a Zone.1 of a public well. 0 ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 20. Commonwealth of Massachusetts c� Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . _ 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for LE MA 02630 OCTOBER 29,2012 every page. BARNSTAB � Cityrrown State Zip.Code. Date of Inspection ❑x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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. El R The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within.200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or 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 16.304. The system owner should.contact the appropriate regional office of the Department. ; C. Checklist 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? t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 20 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3517 ROUTE 6A Property Address. Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE, - - MA 02630 OCTOBER 29,2012 City/Town State Zip Code. Date of Inspection ❑ 0 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)N/A ❑X ❑ Was the facility or dwelling_inspected for signs of sewage back up? ❑X ❑ Was the site inspected for signs of break out? i ❑X ❑ Were all system coniponents, 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? 0 El 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: ❑X ❑ Existing.information. For example, a plan at the Board of.Health. 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) CMR 15.302 PP. A ) 310[ . (5)l 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 D. System Information 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Fora - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 3517 ROUTE 6A Property Address - Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE MA 02630 OCTOBER 29,2012 Cityrrown State Zip code.. Date of Inspection Description: Number of current residents: 3 Does residence have a garbage grinder? ❑x Yes El No , + Yes .Is laundry on,a separate sewage system? [If es separate inspection required] No Laundry system inspected? '❑ Yes ❑ No Seasonal use? Yes El No Water meter readings, if available (last 2 years usage (gpd)): 2011-32,000 2010-67,000 t: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:-Page 8 of 20 IOLN Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3517 ROUTE 6A. Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE MA 02630 OCTOBER 29,2012 Cityrrown State Zip Code Date of Inspection Sump pump? ErYes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design 3 es gn flow(based on 310 CMR 15.203). Ganons.per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial.waste holding tank present? ❑ Yes.❑. No Non-sanitary waste discharged to the Title 5 system? El Yes El No Water meter readings, if available: D. System Information (cont.) Last date of occupancy/user Date Other(describe below):. General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 20. Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Nikwttmr�olf 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE MA 02630 OCTOBER 29,2012 City/Town State Zip Code Date of Inspection How was quantity pumped determined? Reason for pumping: Type of System: ❑X Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El 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): D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were.sewage.odors detected when arriving at the site? ❑ Yes ❑X No Building Sewer(locate on site plan): Depth below grade, 29 INCHES feet Material of construction: ❑ cast iron ❑X 40 PVC ❑other(explain): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 20 1 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 3517 ROUTE 6A Property Address Owner KEITH CARVOLINIS information is Owner's Name required for BARNSTABLE. every page. MA 02630 . OCTOBER 29,2012 City/Town State Zip Code Date of Inspection Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): INSPECTED MAIN LINE WITH SEWER CAMERA, LINE IS CLEAR Septic Tank(locate on site plan): 23 INCHES Depth below grade feet Material of construction: concrete ❑ metal. ❑fiberglass_ ❑ polyethylene ❑other(explain) If tank is metal, list age: years. - Is age confirmed by a Certificate of Compliance? (attach.a copy of certificate) 0 Yes El No Dimensions: Sludge depth: D. System Information (cont.) t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 20 Commonwealth of Massachusetts Q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE MA 02630 OCTOBER 20,2012 City/Town. State Zip Code Date of Inspection Septic Tank (cont.) . t - Distance from top of sludge:to bottom of outlet tee or baffle Scum thickness' Distance from top of scum to top of outlet the or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined?.. Comments (on pumping recommendations, inlet and outlet tee.or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) Grease Trap (locate.on site plan): Depth below grade: feet Material of construction: El concrete ❑ metal ❑fiberglass. ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle l5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE MA 02630 OCTOBER 29,2012 City5own State Zip Code. Date of Inspection Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 20. Commonwealth of Massachusetts Title 5 Official -Inspection - Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments re _ 3517 ROUTE 6A. Property Address Owner KEITH CARVOUNIS information is Owner's Name required p9e everyBARNSTABLE MA 02630 OCTOBER 29,2012 Cit /Town Y State Zip Code Date of Inspection *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert AT INVERT I Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No- , Alarms in working order: ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE - MA 02630 OCTOBER 29,2012 City/Town State Zip Code Date of Inspection 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: D. System Information_(cont.). . Type. ❑x leaching pits number:1 6X6 ❑ leaching chambers number: ❑ leaching galleries number: ❑: leaching trenches number, length: ❑ leaching fields number, dimensions: t5ins-111.10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 20, -04 Commonwealth of Massachusetts r Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE MA 02630 OCTOBER 29,2012 Cityrrown State Zip Code Date of Inspection ❑ overflow cesspool number: 1-6X6 ❑ 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.) 57 INCHES OF LIQUID IN PIT, LEAVING 13 INCHES OF ROOM BEFORE INLET 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 D. System Information cont: Y (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ` t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 20 l Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for BARNSTABLE MA 02630 OCTOBER 29 2012 every page. Cit /Town Y State Zip Code, Date of Inspection . t 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.): 1. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 20 r . ;k6Iy Commonwealth of Massachusetts :.. r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T _ 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. BARNSTABLE - MA 02630 OCTOBER 29,2012 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. ❑x drawing attached separately t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name required for every page. gARNSTABLE MA _ 02630 OCTOBER 29 2012` Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope ❑x Surface water Check cellar ❑x Shallow wells t Estimated depth to high groundwater: 15 FEET 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: pate ❑x Observed,site (abutting property/observation hole within 150 feet of SAS).. ❑` Checked with local Board of Health -explain: I El Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: t5ins•1.1/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 20 I _ Commonwealth of Massachusetts r Title 5 Official -Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3517 ROUTE 6A Property Address Owner KEITH CARVOUNIS information is Owner's Name everypage eve BARNSTABLE MA 02630 . ' OCTOBER 29,2012' ry Ci !Town tY State Zip Code Date of Inspection You must describe'how you established the high ground water elevation: 15 FOOT GRADE ELEVATION BETWEEN INSPECTED PROPERTY AND NEIGHBORS HOUSE WITH NO WATER. MINIMUM OF 7 FEET SEPERATION Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist ❑x 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 ❑x Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•1100 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 20 of 20 L_ _ SIDE 0� Na)w ex i i . TROY WILLIAMS SEPTIC INSPECTIONS ! ' Certified by MA Department of Environmental Protection �� !(' (508) 385-1300 SEp 2 19 Hummel Drive South Dennis, MAfl2660 t� To�yNBFP. ZQ�'i� COMMONWEALTH OF MASSACH S-E"T,TS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION O Q Opp ONE WINTER STREET. BOSTON, MA 02108 617.292.5500 WILLIAM F.WELD 005 TRUDY COXE Govcmor Sccrctary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr PART A CERTIFICATION Property Address: f 7 S�' �`�' t ` Address of Owner: ( /L Date of Inspection: ��o�s /y (If different) ��`� 7 196 y / Name of Inspector: Troy Wi 11 isms Ra, 6ox 1' ?.R I am a DEP approved system inspector pursuant to Section 1S.340 of Title S (310 CMR 1S.000) Company Name: Troy .Wi 11 iams Septic Inspections 4?c,,,�„ S �+6 �� lt41" Mailing Address: 19 Hummel Drive , Swith DPnnis , MA 02660 Telephone Number: ( SOP) 3 8 5-13 D 0 (. 10 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 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 _ Fails Inspector's Signature: _4� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. 1(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. COMMENTS: BI 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. 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 rnetal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is 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. - (—i—d 04/25/91) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 3517 Route 6A,Barnstable,MA Property Address: Beverly Boyle Owner: August 25, 1998 Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) A11,4, 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). Describe observations: 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 pipets) are replaced obstruction is removed Cl 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:. 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, IT APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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 S ppm. Method used to determine distance (approximation not valid). 3) OTHER i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3517 Route 6A,Barnstable,MA Owner: Beverly Boyle Date of Inspection: August 25, 1998 D) SYSTEM FAILS: A//A You must indicate ei;,.er "Yes" or "No" as to each of the following: 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. Yes No. 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. 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 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. 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. 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. El LARGE SYSTEM FAILS: A114 You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above:. The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program' I requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (rwised 04/25/971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 3517 Route 6A,Barnstable,MA ; Property Address: Beverly Boyle Owner: August 25, 1998 Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes, No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving flow r normal rates 8 Burin that period. Large g P ge volumes of water have not been introduced into the system recent) or as part of this inspection. Y JL _ 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. _ The system does not receive non-sanitary or industrial waste flow. Y _ The site was inspected for signs of breakout. _ All system components, excluding 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. The size and location of the Soil Absorption System on the site has been determined based on: The facility ownerl(and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. JL _ Existing information. Ex. Plan at B.O.H. _lC _ Determined in the Ifield if ( any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)J ;r-i-d 04/25/91) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3517 Route 6A,Barnstable,MA Owner: Beverly Boyle Date of Inspection: August 25, 1998 RESIDENTIAL: FLOW CONDITIONS Design flow:,33o_g.p.d./bedroom for S.A.S. Number of bedrooms: . Number of current residents: f Garbage grinder (yes or no): NU Laundry connected to system (yes or no): Vc .5 Seasonal use (yes or no): N6 Water meter readings, if available (last t\,%•o (21 year usage (gpd): 7 ,OUc)y k f!or,J- ) Sump Pump (yes or no): A/o Last date of occupancy:` ��. c Cr COMMERCIAUINDUSTRIAL• /, 1,,1 Type of establishment: Design flow:_gal Ion s/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if.available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of� information: t /+�Nn rni .f ��li✓'S 4 V V {.i I c--. 7(j O :n c dl 7Y'�N. �a Yh c��1'1 L✓' SysterA pumped as part of in pection': (yes or no)_&/ If yes, volume pumped: gallons Reason for pumping: TYPE SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract( Other APPROXIMATE AGE of all components, date installed (if known) and source of information: �s / /�d S�30 qp Sewage odors detected when arriving at the site: (yes or no)—NO (r—i..d 04/75/97) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3517 Route 6A,Barnstable,MA Owner: Beverly Boyle Date of Inspection: August 25, 1998 BUILDING SEWER: A/�fj (Locate on site plan) Depth below grade: Material of construction: _cast iron 40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:_ Sludge depth: T Distance from top of sludge to bottom of outlet tee or baffle: Z-Lg Scum thickness: _/ q cr Distance from top of scum to tip of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee Jrbaffle: How dimensions were determined: pe-.4,e . Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) t �-c s �,.< <, J a O t� a .c 7`YJ c r�. c�G• w•+... t W �r•c u�.•. J` • GREASE TRAP:-6�/q (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 3517 Route 6A,Barnstable,MA Property Address: Beverly Boyle Owner: Date of Inspection: August 25, 1998 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes;_ No Date of previous pumping: 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: Lu e- Comments: (note if level and istribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — 170 k CL PUMP CHAMBER: 'Aj 1'9 (locate on site plan) Pumps in working order: (Yes or No) Alamo in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3517 Route 6A,Barnstable,MA Owner: Beverly Boyle Date of Inspection:August 25; 1998 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: Type. leaching pits, number: �K6 L leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) o , W C- J ..J O 1n!tx t c c�t ✓ 6r.✓ u, CESSPOOLS: N1A S5.e.c (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: e Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(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:_J j/,9 (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.) (revised 04/15/91) Page I or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION (continued) Property Address: 3517 Route 6A,Barnstable,MA Owner: Beverly Boyle Date of Inspection: August 25, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) � � I � I I /000 k. G'xb' la z a I L�w"l• (�, L 3 's (rwlsed 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3517 Route 6A,Barnstable,MA Owner: Beverly Boyle Date of Inspection: August 25, 1998 Depth to Groundwater _ Feet adjusted high groundwatcr level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abuning property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Mus/t be completed) Ls . -T r/` �� /-�vh G T /•C- L N h (, r S D . Q / G h c.A �0C_ f t &A v� N . 7 � cJro� '�✓t w . f�✓ �cv`l. (r.,,i..a 04/2s/97) s � Z4 �`� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a n- r d DEPARTMENT OF ENVIRONMENTAL PROTECTION N ,f t PARCEL, ®®� TITLE �.0T a 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYTASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 3517 Main Street Barnstable MA 02630 Owner's Name: Elizabeth Nill Owner's Address: 108 Lincoln Street Apt 3B Boston MA Date of Inspection: August 23,2004 Name of Inspector: PATRICK M.'O'CONNELL 2004 Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD �A NSTpBLE MARSTONS MILLS MA 02648 Lgµ T0`NH pEP1 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems:I am i p111111 approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: o`��'(N OF _ _ Passes Conditionally Passes ATRI I m Needs Further Evaluation by the Local Approving Authority , :y Fails ; 0r ELL Inspector's Signature: —'')—' Date: 8/23/04FSINSPEG niul�aa`` 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: Liquid level in leaching pit 2' below inlet pipe with no high stains. ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3517 Main Street, Barnstable Owner: Elizabeth Nill Date of Inspection: August 23,2004 - Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titla C Tncnartinn Fn—r,il cijnnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3517 Main Street,Barnstable . Owner: Elizabeth Nill Date of Inspection: August 23,2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Titles i inenantinn Fnrm Ail lqi,)Ann 3 Page 4 of I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3517 Main Street,Barnstable * .. . Owner: Elizabeth Nill Date of Inspection: August 23,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: " R Y Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or . clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool — _X_ Liquid depth in cesspool is less than 6"below invert or available volume is Tess than!/Z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.' ` _X_ Any portion of cesspool or privy is within 100 feet of a surface.water supply or tributary Ito a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis; « performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) - No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CR 15.303,therefore the system fails. The system owner should contact M he Board of Health to determine what will be necessary.to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000.gpd to+15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) ' yes no the system is within 400 feet of a surface.drmking water supply the system is within 200.feet of tributary.to a surface drinking water supply ' _ the system is located in a nitrogen sensitive area(Interim Wellhead-Protection'Area-IWPA)or a'mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E'the system is considered a significant threat;or answered q "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.` Titlo Iq rnenvntinn Rnrm 4/1 S/7nnn 4 - - - Page 5 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3517 Main Street,Barnstable Owner: Elizabeth Nill Date of Inspection: August 23,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _ _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? F 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)) TitlA C incnartinn Fnrm 4/1 Vloon 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3517 Main Street,Barnstable Owner: Elizabeth Nill Date of Inspection: August 23,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Yes with occasional winter use. Water meter readings, if available(last 2 years usage(gpd)): 2002—69,000 gal.2003—103,000 gal.=235 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Pumped two years ago. Source of information: Homeowner( Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM —X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 8/30/90 Were sewage odors detected when arriving at the site(yes or no): No Title G Tncnantinn Anrm 4/1(linen 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: 3517 Main Street,Barnstable Owner: Elizabeth Nill Date of Inspection: August 23,2004 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:—X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: 15' Comments(on condition of joints, venting;evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) ) Depth below grade: 18" Material of construction:_X_concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 8.5' long x 5.2'wide—1000 gal. Sludge depth: 7" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 9" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Precast tees intact_and clear.Recommend aumaine at end of season GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): T; la P% Inennrtinn Rnrm A/1 IMAM 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: 3517 Main Street, Barnstable Owner: Elizabeth Nill Date.of Inspection: August 23,2004 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.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Box level,no solids or high stains PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T41a S incnantinn 17^r 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3517 Main Street, Barnstable Owner: Elizabeth Nill Date of Inspection: August 23,2004 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number: One 6x6 pit 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.): Observed liquid level in pit 2' below inlet pipe with no high stains CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Title C Tnenartinn Fnr r,h 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: 3517 Main Street,Barnstable Owner: Elizabeth Nill Date of Inspection: August 23,2004 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. Main Street l�1 L3 �Z i 1000 gal tank 1000 gal H-20 pit. T1t1P C incn`ntinn 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: 3517 Main Street,Barnstable Owner: Elizabeth Nill Date of Inspection: August 23,2004 4 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 25 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town Groundwater contour map shows water at el. 15 and topo map shows property at el 50.Also is located on hill considerably higher than any wet areas. . r T41P 1 411;i,)nnn 11 � p TOWN OF BARNSTABLE rJ q ` `CATION 35;jj MQ0 4 ac-c—-� SEWAGE VILLAGE 6 tAWIc- M4, ASSESSOR'S MAP 6t LOT3 f q INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 1 000 LEACHING FACILITY:(type) h'i f' (size) l_ dd 0 NO. OF BEDROOMS_,�_PRIVATE WELL OR PUBLIC WATF,,R BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: /30 lab VARIANCE GRANTED: Yes No . i SIDE n H"V 1 i I 777 No. Fics........ �. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiou for Disposal Works Tonstrurtinn Jhrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ' ,�► a 5~f� c3� �GA� '� i lam ' ..........1 _____.......... .................................... ...................... � � ....---...... Loca �� - tio Add ss Lot—ND. a�..4........ _ _. � --- .----------•----- --------- - ------ - - :..(0 _..:. ow er Address Installer Address Type of Building - Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures --------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.......__........... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation 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........................ Q+' -----------•-----------•------------•---••-•-------------------•--------•........-------•------•-•-........................................................... 0 Description of Soil--------------------------------------------------------------------------------------------------------------------------------------------------------••----•------ x --------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- w Nat re of Repairs or Al erations—Answer when applicable-___�J_L d_ �_ �5_..... $-AYJ .. ;C U P it...S .� ...... f L R--1-4:5'1-......I........��y`� ��L_.�,�`-----S ..... � `��S`tom n►2 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmenta de—The undersigned further agrees not to place the system in operation until a Certificate of Compliance een issued the board of health. ��igned . - �- re Application Approved By _ ✓.�.__. J�.�� ...... ............................. ........... ............................................ Date ... Application Disapproved for the following reasons- ------------------------- ------------------------ ----------------------------------------------------------------�----- ---------- ----..___...-- ------------...---------- ---------------------------------------------------------------- --- -------------------------=-------------- Date Permit No. r� ..... . -------------------- Issued Date No-_&l.... ', • ,. Fss........ ..b... :THE COMMONWEALTH OF MASSACHUSETTS .BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal arks-Tonstrnrtion lirrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Itil -H l'W 751. kf 6 can ti �"lA l�- Location-Address or,Lot No. ..............................................._......._...........__.._1 .----•••---•-•--- Owner Address . e��S t- � , 9) -3 -S-�-,o A-(-sue- �a L... mot: ,a -•••.......`_._... ....----•-•••---•---- ...........:....•-------•--•----------- ......-•-•--•---•-•--••�---•-� -•----%--•--=- ----16e:r-•---- "'t Installer Address Pq Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria p•l - Other fixtures ---------------------------•------ ------ t W Design Flow_____ _____________________________________gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'ca.pacity____.__.____gallons Length---------------- Width................ Diameter__._-____-______ Depth.............. 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 ( ) aPercolation Test Results Performed by__________________________________________________________________________ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ------•••--------------•-----------•----••--------------....••••-••-•------.......----•--•----••-•--......................................................... 0 Description of Soil...............................................................................-------- W U ....................... ................................................................................................................................................................................. W Z. ••----•----•-----------------------•-----•-•------•------•----------------------------•---•-••---•--------•----------------------------•----••-•-•-•------------------••-•••••----••--------••••-•----•- U .,Nature of Repairs or Alterations—Answer when applicable._.__. d_.._.C�_ S_ ......f.+Akj.,? L� S•�A tLA__I .�v_----®=� to a ................................................1 .- I "�I = :__..: 7.7._,__7 c... ...... 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 hasbeen issued Py the board of health. Signed G. .. r�. S y------ Date Application Approved By --------� ------- --- 4 a'" - - - - - --------- -rh Dace Application Disapproved for the following reasons- ....................................... ---- ---------------.....-------..... ------ .....---------------------- ------.-- . - -----------------------------------------------------------------------------------------------........................................................................ - - Permit No- --- ��' ..��..7,Z7- Date ------------------ 'Issued ------''�r, '� �' ---- at-...... GQ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE V-er#tftratr of V��TT IImplia re THIS IS TO CERTIFY, Thatthe Individual Sewage Disposal System constructed ( ) or Repaired ( t�Ai.:f.......%i aS�.'�'Gc'� �"'' --- by....................<= c�-�'-�—.:.......... ..._ Installer- --...-----....--..-..-...........'----------'-----------.......-- - --------- --'- .................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...f� .-�..... `.��.. dated --..... -..,1,, '" THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---------------------- - 6.. ---------------------------........ Inspector ----.............. ...... ...... ----.......-....----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No....---Pj_..... FEE.�d_ Disposal Works Tonotrurtinn ramit Permission is hereby granted.__.ei5, c.___/;31Ae>1:_.jr--r�!/,l' ,__ Z...._:- to Construct ( ) or Repair (�) an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit Noo ^ +Dated.. _ -e !`1r .__. DATE 0"~� --------- Board of Health ------------• ..� �� FORM 36508 HOBBS&WARREN,INC..PUBLISHERS i Locus N N ® STREET (RpUTE 6A) 97.74 MAI _ A98.85 -----�8-- 99.45 aalllffio--k Rd 99.73 EDGE OF PAVEMENT o � ranite CB F Ln o o CATCH BASIN -i(�6-----� 'QO - -- 99.15 a N 73�19 A a m m Q 99.56 ® / ' 4 .96 x LOCUS MAP i/ 100.52 10L06 NOT TO SCALE (-� ---- --402- LEGEND 99.64 -- --98-- EXISTING CONTOUR CWN9 /j C) 1 x 100.98 EXISTING SPOT GRADE -$H.-W- OVERHEAD WIRES -G EXISTING GAS SVC. 100,33 -W- EXISTING WATER SVC. / TEST PIT BENCHMARK / �'21,300 S.F. C) 1:- PA,R/CEL ID;,3a-7-gq---GG- / x 104.16 / 103.22 CB / O J 104.26 DECK 107.69 108.75 x I I / 110,02 b m /EXISTING / I Ln I I 109,29 x HOUSE(#3517) 109.64 I I T.O.F.=109.5f x �I m I _ z ( 109.32 / o -- ff .I. o m a, k � . _ 1110.25 109.51 c�br x I 106.08 09.46 PATIO DECK -J 109.55 x 109.48 n i I � EXISTING SEPTIC TANK (TO REMAIN) ( I 9'72 x INV..(OUT)=107.Ot(VERIFY) I �. 109.21 '- 109.19 109.27 `n x o 106.14 1.08.64 `� �:.`- p :pRI VFW. j % "�; -_PAVE -- EXISTING LEACH PIT -- - TO REMAIN CONNECTED FOR FOR ADDITIONAL STORAGE h 107.52 107.54 105.18 106 106.42 _ - - TP-2 VENT BENCHMARK - - p-777- w CTR. MANHOLE COVER - - ( 0TT EL.=10764 r - 0Cn 0 niSE t� `ram 10b,99 S'lS' 1_1 a o PLAN REVISION 7/9/18 103.40 x W4i2a"` I - -- - -.1.-.�� 14' 1) EXISTING TANK LOCATION CORRECTED �,37.5 7 5 - 2) EXIST. PIT TO REMAIN o PETER T. TP-1 L_ -- - -_ C MCENTEE ____-_�2--® �N U'- INSPECTION PORT CIVIL "' BREAKOUT SETBACK No. 35109 x 101.28 STRIPOUT BOUNDARY RECIs��° x 100.35 SEE NOTE 11, SHEET 2 Y 105.24' I CONVENTIONAL S.A.S. FOOTPRINT S 77.28'40" W 100.28 x SHOW PER STANDARD CONDITIONS NOT TO BE USED FOR CONSTRUCTION �y (� t� 25' x 40' (FIELD) = 1000 SF (330 GPD) a E, Engineering by: SCALE DRAWN JOB. NO. Engineering Works, Inc. '"=20' P.T.M. 105-18 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 3517 MAIN STREET BARNSTA�LE 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET N0. MA (508) 477-5313 3/16/18 P.T.M. 1 of 2 Prepared for: D.A. Brown, Inc. P.O. Box 145, Centerville, MA 02632 NOTE: TO PREVENT BREAKOUT, FINAL GRADE SHALL NOT BE AT, OR BELOW, EL.=100.3 FOR A DISTANCE OF 15' FROM THE EDGE SEPTIC TANK OF THE PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET PROPOSED D-BOX AND SET TO 6" OF FINISH GRADE. INSTALL WATERTIGHT RISER & PROPOSED S.A.S. COVER SET TO 6" OF GRADE INSTALL INSPECTION PORT OVER ONE ROW(MIN.) T.O.F.=1O9.2t F.G. EL.=103.0 to 105.Ot CHARCOAL F.G. EL.=108.5t F.G. EL.=109.5t f F.G. EL.=103.5t CON T / CT MAINTAIN 2% GRADE MIN. OVER S.A.S. ALL ROWS INSPECTION L = 68' L = 8' PORT S=1% (MIN.) ® S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC 6" Ilm U-i to"1 " t 4" s _ 11" TO EXISTING 48' LIQUID INVER LEVEL ADD 6 ROWS OF 6 UNITS AT 6.25'/UNIT = 37.5' GAS DAFFtF INV.=102.17 PROPOSED INV.=102.00 • INV.=107.0t D-BOX INV.=99.92 (VERIFY) SOIL ABSORPTION SYSTEM (PROFILE) EXISTING SEPTIC TANK ESTABLISH VEGETATIVE COVER BACKFILL WITH CLEAN NATIVE OR PERC SAND TO TOP OF CHAMBERS BREAKOUT=TOP TOP ELEV.= 100.33 <. NOTES: INV.= 99.92 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INVERTS, PRIOR TO INSTALLATION. BOTTOM ELEV.= 99.00 IIIMIIIIIMI 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE 5' MIN. SEPARATION 2.83' ON A MECHANICALLY COMPACTED SIX INCH CRUSHED TO GROUNDWATER STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 4' (MIN.) OF NATURALLY EFFECTIVE WIDTH=17.0' OCCURRING PERVIOUS SOILS SUITABLE SOILS 3) INSTALL INLET & OUTLET TEES AS REQUIRED. NO G.W., EL=90.0 4) CONTRACTOR SHALL INSTALL AN APPROVED GAS USE 6 ROWS OF 6-HIGH CAPACITY H-20 INFILTRATOR UNITS BAFFLE ON THE OUTLET TEE. WITH NO SEPARATION BETWEEN EACH ROW & NO STONE SEPTIC SYSTEM PROFILE TYPICAL SECTION N.T.S. GENERAL NOTES: 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: -310 CMR 15.405(1)(b): 1) A 2' variance to the 3' maximum cover requirement, for 5' of max. cover. S.A.S. shall be H-20 and vented. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. TO UTILITY POLE 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. C) 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF OD rh THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS 6 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY �6 THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING v CONSTRUCTION. ' PROPOSED ' 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS ' S.A.S. ' IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE --�37.5-�� INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. S.A.S. LAYOUT 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. DESIGN CRITERIA SOIL LOG NUMBER OF BEDROOMS: 3 BEDROOMS DATE: JANUARY 24, 2018 (REF#15,578) SOIL TEXTURAL CLASS: CLASS II - UNCOMPACTED SOIL EVALUATOR: PETER McENTEE PE SIEVE ANALYSIS RESULT-CLASS 1 (LOAMY SAND) ON BORDER OF SANDY LOAM WITNESS: DONALD DESMARAIS R.S. HEALTH AGENT BASED ON FIELD JUDGMENT USE CLASS II (SANDY LOAM)-UNCOMPACTED ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH DESIGN PERCOLATION RATE: 30 MIN/IN (0.33 GPD/SF) 102.0 A 0" 105.5 A 0" DAILY FLOW: 330 GPD SANDY LOAM SANDY LOAM DESIGN FLOW: 330 GPD 10YR 4/2 10YR 4/2 GARBAGE GRINDER: NO 101.0 B 12^ 104.5 B 12 EXISTING SEPTIC TANK: 1000 GALLON CAPACITY SANDY LOAM SANDY LOAM LEACHING AREA REQUIRED: (330 GPD) = 1000 SF 99.0 C1 10YR 5/6 10YR 5/6 • 36" 102.5 C1 36" .33 GPD/SF SILT LOAM SILT LOAM DISTRIBUTION BOX: 6 OUTLETS (MINIMUM) 10YR 5/3 10YR 5/3 USE 6 ROWS OF 6. HIGH CAPACITY INFILTRATOR H-20 94.0 C2(UNSUITABLE) 96" 99.5 C2(UNSUITABLE) 72" UNITS WITH NO STONE & NO SPACE BETWEEN ROWS SIDEWALL AREA: NOT APPLICABLE SANDY LOAM SANDY LOAM 2.5Y 6/4 2.5Y 6/4 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF) (SAMPLED) (INFILTRATORS) 36 UNITS x 6.25 'LF x 4.73 SF/LF = 1064.25 SF 90.0 1 144" 95.5 120" DESIGN FLOW PROVIDED: 0.33 GPD/SF(1064.3 SF) = 351.2 GPD SIEVE ANALYSIS RESULT-CLASS 1 (LOAMY SAND) ON BORDER OF SANDY LOAM PROFESSIONAL JUDGMENT - FIELD DETERMINATION, CLASS II (SANDY LOAM) NOMINAL BED AREA: 17.0' x 37.5' = 637.5 SF UNCOMPACTED, 0.33 GPD/SF NO GROUNDWATER ENCOUNTERED Engineering by: SCALE DRAWN JOB. NO. PROPOSED SEPTIC SYSTEM UPGRADE PLAN Engineering Works, Inc. 1"=20' P.T.M. 105-18 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. 3517 MAIN STREET BARNSTABLE MA (508) 477-5313 3/16/18 P.T.M. 2 of 2 Prepared for: D.A. Brown, Inc. P.O. Box 145, Centerville, MA 02632