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HomeMy WebLinkAbout3522 MAIN ST./RTE 6A(BARN.) - Health 00 3522 MAIN ST. /ROUTE 6A BARNSTABLE A = 085 1166 x 4 n � � � .'� a •- +,G . Commonwealth of Massachusettsa-- �n Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c , 3522 Main St. Rte 6A � Property Address Schroeder ^ Owner Owner's Name Lo information is required for every liftBarnstable '/ Ma 5/20/19 . page. City/Town State Zip Code Date of Inspection i:) C+ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not HPS use the return Company Name key. P.O.Box151 r6 Company Address Forestdale Ma 02644 CityTrown State Zip Code 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); I have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/20/19 Inspector's Sign at Date The system inspector shall sub It a co of this inspection report to the Approving Authority (Board of Health or DEP)within 30 d s o mpleting this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: I have not found an information which indicates that an of the failure criteria described ® Y Y in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass.gov 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts jn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 3522 Main St. Rte 6A Property Address Schroeder Owner Owner's Name information is West Barnstable Ma 5/20/19 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 f cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st. Rte 6A Property Address Schroeder Owner Owner's Name information is West Barnstable Ma 5/20/19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 0 The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3522 Main St. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �a 3522 Main st. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)) t5insp.doc•rev..7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -. 3522 Main st. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: 2) 500 gal. Leaching chambers Number of current residents: unknown seasonal Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments J� 3522 Main St. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.20.3): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.coc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: tank 1987- leaching and DBox 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): none t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts !n 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2.75'feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal 8'6"x5' 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness lit Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tees in place no major concrete deay. no visable cracks or leaks. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main St. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Dbox solid no decay or cracks. liquid level at bottom of outlet pipe t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form 1 I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3522 Main St. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: I ❑ leaching pits number: ® leaching chambers number: 2) 500 gal. w/4'stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3522 Main st. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leaching chamber opened system dry with clean sand at bottom 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main St. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 3522 Main St. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately P I I O O I 3 .2 _ 23/(0I - 34 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r-- c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments >r ,V 3522 Main St. Rte 6A Property Address Schroeder Owner Owner's Name information is West Barnstable Ma 5/20/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater then 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: plan on file at own hall 2 test holes done#1 no G/W at 148"#2 no GAN at 180" bottom of leaching chambers at 72" Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 f . ' Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st. Rte 6A Property Address Schroeder Owner Owner's Name information is required for every West Barnstable Ma 5/20/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. Z B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page.. City,Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. Cape Cod Title Five � Company Name Company Address 6 keefe crt ma 02632 Cityrrown State Zip Code Centerville Si13522 Telephone Number License Number B. Certification 1 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 16.000).The,system: ® Passes ❑ Conditionally Passes ❑ Fails r ❑ Needs Further Evaluation by the Local Approving Authority 5/6/2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Ins cti Fonn:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A). System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This system contains a 1000 gallon tank a Concrete distribution box and two 500 gallon concrete chambers. The sytem was upgraded in 2001 B) System Conditionally Passes: ❑ One or more system components as described in the`Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 3522 Main st Property Address Robert Jackson Owner Owners Name information is required for every Barnstable Ma 02634 5/6/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 3522 Main st Property Address Robert Jackson Owner Owner's Name information is Barnstable Ma 02634 5/6/2014 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. I ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: This system contains a 1000 gallon tank a Concrete distribution box and two 500 gallon concrete chambers. The sytem was upgraded in 2001 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d 2012 58,000 g ( y g (gpd)): 2013 54,000 Detail: average 105 gpd Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes,❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Currently Occupied Date Other(describe below): General Information Pumping Records: Source of information: Home owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest- inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DE approval. ❑ Other(describe): 500 gallon chambers t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 13 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ® cast iron ® 40 PVC ® other(explain): Distance from private water supply well or suction line: NA feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2ft feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ® other(explain) If tank is metal, list age: _ years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Cornmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 18" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 28" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank was pumped in 2012 Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Coynmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was pumped in 2011 Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L�M 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level, solid and at normal level 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.): no signs of carry over Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 IL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st Property Address Robert Jackson Owner Owners Name information is Barnstable Ma 02634 5/6/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Chambers are dry and there are no signs carry over. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of hydrualic failure Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 TOWN OF BARNSTABLE_ LOC:AUMN 3 o'Z n9A i iJ S i SEWAGE # AQC U— VILLAGE 4V3 G ASSESSOR'S MAP & LOT Sit- 3 Z i INSTALLER'S NAME'&PHONE NO. A+R C AJ$IC,- 0, SEPTIC TANK CAPACITY ,Q c 0 6-L LEACHING FACILITY: (type) of—.6416 4.L 62M 6 e--QS (size) NO. OF BEDROOMS_ U I BUILDER OR OWNER ALA/U CLi ii&, R —I)PERMITDATE: — i Separation Distance Between the: Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on situ 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 ,A- 1-33 � A -Az 3i < A►= =3 4' )rRaivT , Z-3 A �o O j 41 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 3522 Main st Property Address Robert Jackson Owner Owner's Name information is required for every Barnstable Ma 02634 5/6/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft'feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 1f checked, date of design plan reviewed: 3/5/01 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Town Records Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 3522 Main st Property Address Robert Jackson Owner Owner's Name information is Barnstable Ma 02634 5/6/2014 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE Lbi AT',7N 3 5,2 a A 1A 1 lJ S'T' SEWAGE # A00 U'- 1014o VILLAGE 6A6W5t4&G' ASSESSOR'S MAP & LOT S 17- 3 2 INSTALLER'S NAME&PHONE NO. A+B CAM�o SEPTIC TANK CAPACITY ,��®®0 &L . LEACHING FACILITY: (type) cZ° -S5'60 J— C4M13ERS (size) 3 X, NO.OF BEDROOMS BUILDER OR OWNER ALA1U CL' 1&)&EA, PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exisi 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 �e e O as O a e e e A _ o T�—i '- q. �' -- QfjGlG�r�G—oP �-,N No. %0 ®� ' Fee v ul>✓� �� THE COMMONWEALTH OF MA SACHUSETTS Entered in computer: Yes l PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS f,,-M 6pq application for �Digooar *p$tem Consaructivn jermit Application for a Permit to Construct( . )Repair( �de( ),Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. /A Owner's Name,Address and Tel.No. Assessor's Map/Parcel �+� Mete• Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. Lj Type of Building: Dwelling No.of Bedrooms_ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow TS gallons. Plan Date la -/d- €9- Number of sheets / Revision Date > Title ,j f014,YI Size of Septic Tank loan exiJl2L,�Type of-S.A.S. /aUa Description of Soil Per 0"Jr Nature of Repairs or Alterations(Answer when applicable) 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 t e Envydn—lnental Code and not to place the system in operation until a Certifi- cate of Compliance has been istsued by this B ar of ealth. Sign Date ,U Application Approved by Date Application Disapproved for the following reaso s Permit No. i Date Issued ——————————————————————————————————————— 1 !r• i lej,)G—,)P00 4 1 ,P) J)ec,��)g N iN J �!ls C ry No. f �! + ' l ie � Fee A •6OMMONWEALTH OF MA SACHUSETTS Entered in computer: \ Yes V PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS • 01pprication for Migogar *p5ftn '66ngtruction Permit Application for a Permit to Construct(' `)Repair( a6p�grade( )Aband n( ) ❑Complete System ❑Individual Components 1 Location Address or Lot No. y�/ A Owner�s'�Name,Address and�Tel.No. / �Assessor's Map/Parcel v®c!'' Installer's Name,Address',and Tel.No. esi r s.Nam_e,Addrress and Tel.No. Type of Building:.._ Dwellings -No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ?� C) gallons per day. Calculated daily flow �� gallons. Plan Date /d -i ci - Number of sheets / Revision Date 1 ^G 0` Title ,Size of Septic Tank Type of S.A.S. / a o 4 y/��J � / " Description of Soil -e s- P lid-A Nature of Repairs or Alterations(Answer when applicable) 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 thf Envi nmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bla oTealth. Signed'\ ' Date Application Approved by f 1 `I Date Application Disapproved for the following reasotas Permit No. 0 l Date Issued —————————————--———————————————— ——— —— THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( graded( ) Abandoned( )by / ,_(JC U # 1 at 3 Saa Ip_rI046 ha e n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ''' ated 3-3 —01 Installer Designer The issuance of this a shall not be construed as a guarantee that the syste 11 func son as-leesigned. Date r+/�� � +Inspector ""r^ � `f'�'�f No. �--------------------------------------- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migogaf 6potem Construction Permit Permission is hereby gran�tte t® -ons ct( ) e ( U grade, ( )Aba do ( )• -- System located at ! and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mu/ be coketed within three years of the date of this Date: A roved b � PP Y a /) �/y ' s ,u 35Z..Z M TOWN OF BARNSTABLE LOC:ATI-DN SEWAGE # VILLAGE /3,4rciv,57.-4/3 c/z ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO.�/�l/GP, aro SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 0 % (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER /° BUILDER OR OWNER iS+X/f L /po i/ art C/;17 c-r DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Fin,✓? F ........._............ _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .D .11/..........o Tr9 -1-0e-----......�'...�.... Appliration for Uiivnaal Workii Tomitrurtiun jhrmit Application is hereby mad four a .�rmitt9 Cons uct !P) pyalif; ) an Individual Sewage Disposal System at: � � 1 1 IV � f RJ1 - __'. ............................. ........__ ........................................... .. .-Location-A dress or Lot No. -•--------•--------- .......002.&?,........ Address Installer Address U Type of Building Size Lot fq� Z$�..Sq. feet--" Dwelling—No. of Bedrooms.......... ............................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ............... No. of persons...._............._..__.._.. Showers — Cafeteria 04 Other fixtures -------------•-.•-----_-•-•. W Design Flow...............%,57 r................:.gallons per person per day. Total daily flow........a..*2.0.....................gallons. WSeptic Tank—Liquid capacity./POQgallons Length_ .'lo___ Width._.:l®... Diameter................ Depth._...__.__. x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......../......... Diameter'.../Ao...... Depth below inlet....�4............. Total leaching area..22�Z..sq. ft. Z Other Distribution box (d--) Dosing tank ( ) '-' Percolation Test Results Performed 4 AEX....... Date.... VIll$ ... as Test Pit No. 1-<'..Z..minutes per inch Depth of Test Pit.... Depth to ground water../2-,.ae�k ... Test Pit No. 2................minutes per inch Depth of Test Pit../.46.R.'­. Depth to ground water-1il_ a Q.:-y _"._.�.t�� ..s�� :o14-------.....#w.--... .3. .`:fro��.GQ� i : . xok O Description of Soil...... ! .'_ 6`.._.� �R. `s 15!h� ----------•------------------3_�_�e`12 ._�2460 SeV to.------ 10<�_/8'� / eQ,� '.of3S/' 55'!91v,0---------, 0`-/6 /�'J- 1� U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: .. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI ITL% 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed__N,4�a --------------------•----------••-- -------------------------- -- D to Application Approved By-- _ y -- •--••••---•-••---••-•-•••----•-•-•--•---•.....-•-----••••--•••-..... ..._!== =7 Date Application Disapproved for the following reasons---------------•--.....---•--•--•------------•-•---------------•----------------------------••-•--•----•-•--•-- ---••----•--•---•••....•••-•-•-•-•....•-•--•••--•-----•-••-•--•••••-•-••-••--••••-••-••..................••---•--....-•-•-•••-•--•----------•••.....-----•------•-••-----•-----...--••-----•--•-•---•--- Date PermitNo..... ............. --•--------------- Issued........................................................ Date No.. 'Z_Jjbk l Fs �....._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........Tv l2�..........OF.. i��<t .'.d:?r..:a. .1, .Lr`=........�•...��! Appliratiun for Disposal Works Tonstrttr#ion rrruti# Application is hereby made for a Permit to Construct (l/) or Repair ( ) an Individual Sewage Disposal System at: r:----.-.-. -12due............................ ...... •.-c Location Address or Lot No. Y._......: y!.CaCI ..5.......----•-•----• ............. Owner r .•-• Address a ........................•---......... •-: f.....-•------------------....... ....----- ----- ....................... Installer Address U Type of Building Size Lot a�.% -4..Sq. feet 1 Dwelling—No. of Bedrooms...........a*9.......:....................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building No. of persons............................ Showers Ga YP g --------•------------------- P ( ) — Cafeteria ( ) p•' Other fixtures .•-----•---•---•••--••-••---•-•.............................. d W Design Flow...............ems:-..................gallons per person per day. Total daily flow......... 9?.0.....................gallons. WSeptic Tank—Liquid capacity./_O.0.?gallons Length...:/:-46"Width.�"=6.'�Diameter................ Depth.: .. "/ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No---------/..:........ Diameter.....!U....... Depth below inlet.....6.......... Total leaching area...ji?. :.sq. ft. Z Other Distribution box (k-) Dosing tank ( ) '-' Percolation Test Results Performed by...E/9'dv19�, ......4..../). G L..E)' Date....t Z1..�� .. a a Test Pit No. 1�.:..Q minutes per inch Depth of Test Pit...../... U_�� Depth to ground water... '_ �. Test Pit No. 2................minutes per inch Depth of Test Pit...1..10 :. Depth to ground water..! q.y . 9 V..L ko!9.{2se.. su/35�1� ?kek......� O Ham? Lib /.�j�/ its .7'" /j U Description of Soil.......... .0'. 40 ...CGS�': ... f� ✓ �..,...C.A.9.Y ....... W --•-----•------------------- ��0•----�8'�•--•-✓ri_�_U,-G° `�' S r4'e•-- �7i 0..........l4?4?..:��vT- '47t....�s UNature of Repairs or Alterations—Answer when applicable............................................................................................... --•--•---------------•-•-••-•-••----...........--•----•---•----•-•-•---.............................-----........-•••--••-----•-.....---•--------....--•--•--•-•--:-....---......••••----..........._... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed1C .... ................................... .........................._.... ��_-- ��_ s ... Date Application Approved BY . _, ......... .............•-•••-•-•--------•-•-•••--•••--------•----..... ---------- Date Application Disapproved for the following reasons:........................................... .................................................................r.. i ........................................................................................•-........................................................................................................... Date Permit No..... ........... Issued_.................................................... ... ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......Tom./ !..........OF...... 'r�'c�. ..T.. 4 ..... �A, Tntifirtt#r of Toutpliam THIS IS TO CERTIFY, That the Individual Sewage Disposal Syste o structed (4 or Repaired ( ) by..........C_rr...... :.....ki;n� .L.... C'�.�'.`�.?-.... .4 .......�!.M.-!�.�. _....Installer .............................................................. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. ;..:T�..__a.f. _ ?..... dated-...i�.(.r., �1. ........................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION $ATI.SFACTORY. (� taoj DATE................................... -3..'�..-----........... Inspector......... ... ...........=aSTti!Cj J .................................�.... t.... �V �,,• �NGIN�EE ERj�F� S.fR`G� f SIGNING '\ 'pM Gc,f���E� THE COMMONWEALTH OF, MASSACHUSET7,SAL�.A WAS `�N• BOARD OF HEALTH I AC- 05DA GE10 ...... . Fir y`3'......... Disposal Works Qonsfrur#iott rirutit Permission is hereby granted.........4: 'L..................-•--•---:.........-.-•----•---.........................................................____ oe to Construct (! or Repa;r ( ) an individual Sewage ks System at No.. .._..�5:..�.5�►'- - !-�1� y :2 l •........................................................... Street Per. --as shown on the application for Disposal Works Construction N 5.... .... Dated...... .;.R JL U�C`.....--....... DATE.................o b -8 .................................. Board of Health FORM 1255 A. M. SULKiN,. INC.. BOSTON EDWARD E. KELLEY REG. LAND SURVEYOR CUMMAQUID MASS. 02637 TEL : (617 ) 362-2266 Town of Barnstable Dec. 30 , 1986 Board of Health Hyannis, Mass. Ref: 85-1166 Blakely- Builders, Lot # ", Redwing Lane , Barnstable Af impervious material was removed 1Q ' beyond leach area and clean sand was used for fill. The system meets all requirements of Title V and the Town of Barnstable Health regulations. OF l�lgs ��� RFsp ED EARD s , c LN a e. a CA No. 26100 ca eg. gjr,p Profess onal . rs Re 4� t � i Land�Surv�e.yor SANIiARIA� yw h l i � I 1 3 111 417./0' I � - - 98 ` semen GrLG�/• TDB pF ' t io rI„Ki DZIVE n + LoT# �i ¢ N Gor w9 ' I ki LeT o✓S/ 1 v 7 � I I _ i I II /\/OTL—'�- GrZ�I�iT?10NS .L�A.�LC� ON ASsuMe--D DfM-ups. LID CAT10N .Q'`?�.'t!'S'�!9 LNa /`9�9ss... ... SCALE . .!i._�oo' . . . DATE DG-z /l �yBs PLAN REFERENCE ��� ti /"/icL c2GSZ 2�i3GT� 772c•S7- KELLEV "No. 2�100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v �� AECiSTE`��� �� s���Rt LAY©v I CERTIFY THAT THE SHOWN ON THIS PLAN 19 LOCATED ON THE GROUND A9 SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF i` WHEN CONSTRUCTED. DATE � . . . . . REGISTERED LAND SURVEYOR IL V ♦. y t •,, SH��T Z of+.Z S'r/6- `7-5 TOP OF FOUNDATION I CONCRETE COVER CONCRETE COVERS 4"CAST IRON77II2 MAX. � ' OR SCHEDULE 40 ,E 12"MAX. 4"SCHEDULE 40 P.V.C.(ONL() ` P.V.C. PIPE PIPE- MIN. LEACH PITCH 1/4"PER. PITCH 1/4..PER.FT. PIT PRECAST J T LEACHING o' INVER ° %•`'' e EL„33,z8.. INVERT INVERT I . PIT. OR p , SEPTIC TANK 3. qo DIET. 3Z.Sz W S'' EQUIV. INVERT EL....:.. . . . BOX . EL......... ' : >x '% /O6O .. / U♦ ��• e' EL.,33,07 GAL. INVERT INVERT 6 vQ :;i: 3/4"TO IV ' ELA;-.?� :'' U.o WASHED 14 w W STONE •tL /0 W DIA.�2— lo, DIA.:fA N° . , PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM N /N 79`�"`r's��r.�x�� lt i 7/L�LE7iUI R7�&A�37 /Fx'wsD /O�.B".vD 7D DW 0'7 &V&D NO SCALE '9''D Ai�P445WV w'rN CE'h" SOIL LOG WITNESSED BY : DATE .oGT!i !�BS TIME. Z �01'.9?1. . . :r�''�S . . . . . BOARD OF HEALTH TEST HOLE i TEST HOLE 2 , ENGINEER ELEV. . .3G.�/o . . . ELEV. .3G: , , DESIGN DATA : 4a pz,33.4-o GZ.33,Zo ,yam /yam NUMBER OF BEDROOMS z. . . . . . . . ♦ , �• .SA+�D SAr.p 4-z.3490 7i" TOTAL ESTIMATED FLOW . . 220. . . GALLONS/DAY, �, 30♦to '78 S o. CLAYBOTTOM LEACHING AREA SO.FT. /PITIC.A D. /7ou C SIDE LEACHING AREA /BB,.Sv SQ.FT./ PIT 47/C.P,D, ' e2,zt.go ez, u,zo GARBAGE DISPOSAL . N♦?A?4 . .(50% AREA INCREASE). "AID. Z` -pg. CoA�2s� s,�.o TOTAL LEACHING AREA . . 7< SQ.FT /Bo Nz SAID " PERCOLATION RATE . .S S�`�: . . MIN/INCH �z, z/.�o itB ,Zz.zv LEACHING AREA PER PERCOLATION RATE .V.-q.. SQ.FT./ap.A .!!?. .WATER ENCOUNTERED NUMBER OF LEACHING PITS . .4^/ .O/7. w!7?V . APPROVED . . . . . . . . . . . . . BOARD OF HEALTH �'�° •D/=,•S77?�/Er oN,i}ZL S/DB.s: . DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AGENT OR INSPECTOR OF o EDW Gl N IO . . . . . . . . . . . . o L LEY a. 49 NO. 2610fl "r ''ers 9FGI$TER���s �° TEAS L L26� s�nrtan�a�' PETITIONER : j ��y. IjviL�E�s -- - - Q Rm7 r ws �tiS�.Z M SOWN OF BARNSTABLE LOCATION � � SEWAGE # ' VILLAGE -- SST/-� C/Z ASSESSOR'S MAP Si LOT r JNSTALLER'S NAME PHONE NO.��/�G� / s ' SEPTIC TANK CAPACITY G t 1W, LEACHING FACILITY:(type) ' �° (size) 6 w 3�51 NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER /° -�--_ BUILDER OR OWNER L r9 K/f C /yob /7 y /tea n/ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED• # � VARIANCE GRANTED: Yes a NO ------------------ fir,. ��,. -- ------------------- "7 J t STAa�� f/Pneg',z I� Cos ••i',' 16 s7a.,.E ,I I� t • ', \ I1 I ••,' ''1 t I I 1-7-S 13viLT s/TZr- 1N OF �tgsf ( `^ ;i f�GG/fiiv A?%ja say CLING o EDWA D ' �;�' D&IC. /a E r' / / c o. 2610 O o EASE/16�/T /co AGCE3s774�7/ Cwyr>Ayu/D AAevoy T..�c. i r -