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HomeMy WebLinkAbout3606 MAIN ST./RTE 6A(BARN.) - Health 3606 ROUTE 6A, BARNSTAB E A- iL l 1 d o i� — v Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 3606 Main st ` Property Address p, John and Alexander Hayden Owner Owner's Name information is : required for every Barnstable Ma 02668 2/15/19 F= 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. Inspector Information 6[-# /31o3Z on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane OQ Company Address Cotuit Ma 02635 City/Town State Zip Code 508-364-9587 SI 13522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 2/17119 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to s the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For F;. �. ., p m �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 I 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 any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1500 Gallon septic tank as well Y p el as a concrete distribution box and two 1000 gallon leach pits. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is Barnstable Ma 02668 2/15/19 required for every page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a .F _ 1e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments B 3606 Main st u Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4 System Failure Criteria y to a Applicable to All stems: pP Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form � a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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. I ❑ ® 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface u ace Sewage Disposal System Form Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 page. Cityrrown 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 a//inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 212 GPD 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts 1p Title 5 Official Inspection Form . b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information isequired for every Barnstable Ma 02668 2/15/19 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 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2014 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is Barnstable Ma 02668 2/15/19 required for every 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: 11/23/1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1811 Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection ection Fo rm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name y information is Barnstable required for every Ma 02668 2/15/19 page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" 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 is sound. Tee's in place 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 u 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 page. Cityrrown 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:. bate 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 1 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name isrequired for every Barnstable Ma 02668 2/15/19 page. Cityrrown 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 Level 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.): Camera inspection of distribution box showed no signs of failure. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 page. Cityrrown 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: Two leach 1000 Gallon pits Type: -® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 1 Commonwealth of Massachusetts p Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 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.): No ponding no signs of failure 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3606 Main st `V Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 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 �9 Title 5 Official Inspection Form !� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4' 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is required f Barnstable Ma 02668 q d or every 2/15/19 page. Cityrrown State Zip Code Date of Inspection D. System Information Cont. Y (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 z Page 1"4 of t j OFFICIAI, , INSPECTION FORM :NOT FOR VOL SvasuRFACE's �ARYASSESSME y EWA NT GE DIS S ,POS.AL SY �STE1Vi I.IYSPECTIONF R1VI S PART TEM MORMA YS C ..-Property Address«. '- '`"• 6 {continued} eDt .� r�arnstafi! esq � p ��Owner � , .. --�ary Drsarcrn Date of Ins�ectjon�` x�2�ember j7 � _ 4 , , SKETCH OF SEWAGE DISPOSAL;SYSTEM 'Provide a sketch of thesewage:drspasaT.system.rnciuding ties to at,Ieast`two benchmarks Locate all.wells wrthtn i 00 feet Locato where public water supply raters the Cenc e landmarks or:' . burdin4. t.. hU x r s Fra 3 !g 771b 1,. y �� , 3� � °Zcora�� R • r _ y' s 2In O kx I Commonwealth of Massachusetts - Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3606 Main st v Property Address John and Alexander Hayden Owner Owner's Name information is Barnstable Ma 02668 2/15/19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: 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 Commonwealth of Massachusetts Title 5 Official Inspection Form rc Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3606 Main st Property Address John and Alexander Hayden Owner Owner's Name information is required for every Barnstable Ma 02668 2/15/19 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. ❑ 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 MOW., Massachusetts Massachusetts Department of Environmental Protection Bureau of Resource Protection Well Completion Reports Well Driller V Please specify work performed: Address at well location: tfr: New Well Street Number: Street Name: c3606- _ MAIN ST'-' l� Please specify well type: Building Lot#: Assessor's Map#: o Irrigation 318 Assessor's Lot#: ZIP Code: Number Of Wells: 54 02630 y+? City/rown: Well Location BARNSTABLE In public right-of-way: GPS r...Yes (7,No_ North: West: 41.70245 70.28963 Subdivision/Property/Description: Mailing Address: click here if same as well location address Property Owner: Street Number: Street Name: SCHROEDER C 3606 v MAIN ST L City/Town: yState: Engineering Firm: �BARNSTABLE_ , MASSACHUSETTS ZIP Code: 02630 Board of health permit obtained: ........................ is Yes C.Not Required Permit Number: Date Issued: CW2020040 12/1572020=� Massachusetts Department of Environmental Protection LlBureau of Resource Protection—Well Driller Program Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock uger Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY .............................................................................................................................................................................................................................._....................................................,............................................._..._........................................................... .................................................... From(ft) To(ft) Code Color Comment D stem in drill or ddttto Extra fast slow Loss or a n s drill rate offluid ............................._......................._.. ....... ._..-_-._. .....................€....................................................................e.._.... .... ..----_.._..__.._........_..........................._................ ....._................ ................................._.....::......, 0 20 (Silty Sand And G Brown Fast f'Slow ( ........ ........... .,.......... YES NO Loss Addition ..............._.......................................................-...............................'. �................�.......—.......�............................................... .......... ....._............ 20 40I Fine To Coarse S!11.1Brown Fast YES N0� w Loss Addition y t r,Slow --- 40 50 Medium Sand �j Brown Fast t Slow ....._...-_._ YES NO .................. Loss Addition WELL LOG BEDROCK LITHOLOGY ........................................................................... ..........:....................... ...... Loss or Extra Drop in Extra fast or Visible Rust From(ft) To(ft) Code Comment addition of Large drill stem slow drill rate fluid Staining Chips p ........................................................................................................................................................................................................................................................................................................................................................_........................-._....................._............... ..... .qw ..........m y.......ym. .... .................. ....... ........ tW $ f°` t 3 t Code Yes; Yes' YES NO Fast Slow Loss Addition ADDITIONAL WELL INFORMATION Developed i�,Yes f`-No� Disinfected � fsYes-------------------- °No Total Well Depth 50 Depth to Bedrock Surface Seal Type None racture Enhancement t' Yes ............................................... ................ CASING is Casing above ground. ..................................,............-................................_.......... ............ .................................................................................................._..._....... From To 'Type Thickness Diameter Driveshoe 0 146 Polyvinyl Chloride Schedule Yes; SCREEN No Screen From To 'Type Slot Size Diameter _.._._............................ ...................................................................................................................................................................................................................................................................,............................................_....................., Stainless Steel Well Point • 0.010............ 46 50 4 ............................... WATER BEARING ZONES I DRY WELL: From j To Yield(gpm) —�—-- `35 i 50 12 E.................................................................... ............................ PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description i Horsepower Submersible.................................................. l' 1 Pump Intake Depth(ft) 45 Nominal Pump Capacity(gpm) 20 <R o Massachusetts Department of Environmental Protection tl Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) ANNULAR SEAL I FILTER PACK From To Material 1 iWeight Material 2 _ Weight Water Batches Method Of (gal) (count) Placement .........._................... ............................................._............................,..... ,.................... __.......... Ali Choose Material I Choose Material --Choose One WELL TEST DATA ..............................................................................................._....................._...................................................................................................I........................... ....................._ Date Method Yield(gpm) Time HH�P�)mped BGS)ing Level(ft (FIHe1ANo)Recover Recovery(ft j` .. _.................. ..................................................................................................... ....................._......_................._...................................................................................................G........................................................ ] T 02/18/2021 Constant Rate Pump12 01:30 40mm 00:01 35 ._.li �� �.................`_.... ..................�_ �� ................................................_..... .............................................................................._.........__.........................................._.. WATER LEVEL Date Measured Static Depth BGS(ft) Flowing Rate(gpm) 02/18/2021` 35......._....................... 12 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. WILLIAM Monitoring[M] Supervising Driller DESMOND, DrillerURQUHART Registration# 877 Signature PATRICK, DESMOND WELL Firm DRILLING INC. Rig Permit# 0551 Date Job Complete 03/25/202 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. ENVIROTECHLABORATORIES,INC. MA CERT. NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: Desmond Well Drilling Location Address: PO Box 2783 3606 Main St. Orleans, MA Barnstable,MA 02653 Lab Number: DW-210545 Collected By: Desmond Well Drilling, Inc. Date Received: 02/18/21 Sample Type: Irrigation Well Specs u � �«. �.� .�ti m f: *r6"�y.- �Y TM - G " ndrr LvcatJo nSouree Bate Cetleeted, 7°'ime�Cvllet�ted Cenimerrts �q �-.-..,,G,i.;.':mr� G ,a+�.��VSR.Ift.y:�'r»� r �",A''l��;t} 'cA ht^ ���k&i, a B;Wiw"�Y�a _a• ' %t '�'Mm'm+'p�` ?�**�"' �, r.M,+,.�; u._,�.�. y,. ��.�.:'.�..wx..-earas....,...u.. s. ..,vsti�:wc..• a ._aa;.,uwre.,«.-.� a., ,x-.+.,rez+x"s+`r: f Analysis Requested Units Recommended Limits: Analysis Resul 11Jethod Date Analyzed Analyzed By Total Coliform CFU/1.06mL. 0 - '0 SM9222B 02/18/2021 -KF @ 14.00° - - pH pH units 6.5-8.5 6.01 SM 4500-H-B 02/1`8i202 SD Specific Conductanceo umhos/cm' 500 217 EPA 120.1 02/18/2021 "SD Nitrite-N mg/L 1.00 <0.006 EPA 300.0 02/18/2021 SD Nitrate-N mg/L 10 0 1.50 EPA 300.0 02/18/2021 SD Sodium mg/L 20.0 24 EPA 2007 OM2/2021 KB_ Total Iron _ mg/L_. 0 3 _._ 0.02 .�. EPA 200....7 02/22/2021 ---KB Manganese.. .. ....._. m.g/L 0.05 0.180 _,...EPA 200 7 02/2212021, KB Comments: pH is below recommended limit and may have corrosive characteristics. Sodium level is not a health hazard. Over a lifetime,the EPA recommends that people drink water with manganese levels less than 0.3 mg/L and over the short term,EPA recommends that people limit their consumption of water with levels over 1.0 mg/L All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. Water meets EPA.standards and is suitable for drinking for parameters tested. ArDate 2/22/2021 Ronald J.Saari Laboratory Director BRL=Below Reportable Limits 'See Attached Page 1 of 2 oCertifrcation is not available for this analyte for potable water samples.. l TOWN OF BARNSTABLE Lf:CATION 3GO(o_IV AA SEWAGE # �x xa,LAGE (3A�n S�-A�� ASSESSOR'S MAP & LOT 3J rr- OS 11vSTALLER'S NAME&PHONE NO. S SEPTIC TANK CAPACITY LEACHING FACILITY: (type) G x 4 P. rS (size) /O NO.OF BEDROOMS__._ BUILDER OR OWNER G. 1b. 1SA(cth A PERMITDATE: 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 exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ng facility) Feet Furnished by y�'��� t 0/ �J J O a I yy a ay SI � 3 a y TOWN OF BARNSTABLE ,ti1.9CATION !�Off' A SEWAGE # 1,i- 7� VILLAGE Z�14 4�NS rA hlLfSSESSOR'S MAP & LOT INSTALLER'S NAME.& PHONE NO. 5 0 AI SEPTIC TANK CAPACITY %-T, O LEACHING FACILITY:(type) (size) /.D O 0, U (fq c? NO. OF BEDROOMS -/ PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER. P o4vo DATE PERMIT ISSUED:'. DATE COMPLIANCE ISSUED: j/ "22 VARIANCE GRANTED: Yes No j/ , � o THE COMMONWEALTH OF MASSACHUSETT4 gam v�tt pepanment BOARD OF HEALTH OWN OF BARNSTABLE pate Applira#iou for Uiipnsa1 Workii Tiltuitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair �X4 an Individual Sewage Disposal S swat Y Ob Route 6A Barnstable 4 r •---•--••---•---------•--...........................•..............................-•••--....... .............................................. -------------------•---•------------------- Location-Address or Lot No. Parsons ......................_.......................................................................... ............................................. ------------•-----------•-------- ...--........._ Owner Address W J.P.Macomber Jr. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling X No. of Bedrooms.............. ......__._.___._ .__..Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ..... No. of persons....................... Showers — Cafeteria Ga Other fixtures -----•------------------=--- -:......----- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----_---------_- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ ,.� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--___-_-_____-__--. --. G%, Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ 0 Description of Soil....................Sand & Grave 1 -----•---•-•----------------------------------------------•---------------------------------------------------•-•---•_----- x U ------------------------------------------•----•--...--•-----------•------••-----------------•--------------•--------------------------•--------------------•------------------•---••------------------- w ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ V Nature of a it r Alterat'o s—Answer when applicable.__-1-1500 gallon- tank 1 distr bU_�,pn box an �800 gafion leach pits. ----------------------------•-------------------•------------------------------•--...--•--------------------•-------------------- --------------------------........................................... 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 Complia e has be i ue y the bo rd health. Signed ..--- --- -- ---- ....... .......... ,--------------------------- ....11/�O/92........... _. Da- Application Approved B ' v �J�.-.--- . /� Z 7- . ... .... ................................. Date Application Disapproved for the following reasons- ..................................................----------------------------------------------------------------------------------- ............... .................................................................... - -----------------l--------------------- ---------------------------------------- ' ------. Issued ----�/-- P_Permit No. e Dare 3/? No. '' , � e * � FEz— _2�a 0a 20 THE COMMONWEALTH OF MASSACHUSETT9 - BOARD OF HEALTH "'TOWN OF BARNSTABLE Application for Disposal Works Tonstrnr#iun Errant Application is hereby made for a Permit to Construct ( ) or Repair .(X�, an Individual Sewage Disposal S36 6a Route 6A Barnstable ...---•-•-- __----_----------------------------------------------------------------------- --------------------------------------------------------------•---------------------.. Parsons Location-Address or Lot No. .. ---------------------------------------------------------------------_--.-----__ --- W J.P.Macomber Jr �n� Address a ..............•-•---•••••••...._........ ---------------------------------•--------- ------------------------.----------------------------------------------------------------------- Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwelling X No. of Bedrooms..............4............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building No. of ersons---------------------------- Showers L11 YP g --------•------------------- P ( ) — Cafeteria ( ) P4 Other fixtures ------------------------ - - W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid*capacity------------gallons Length---------------- Width---------------- Diameter---------------- Depth-_----_-..---_-- x Disposal Trench—No..................... Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No---_---------------- Diameter----__..-__-.-_--__. Depth below inlet-------------------- Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- a a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water---•_--___--_-------___- 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_----•-_--_-•-------_ ------------------------------------------•-----•----••----------------------------------------------------------------------------------------------------- 0 Description of Soil--------------------Sand & Gravel - - -----------------------------------------------=--------------------------------------------------------------------•------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V Nature of gepairg� or Alterations—Answer when applicable-----1.-1500.ga__1__l___o__n______t__ank_--1... -is tribut on box and 2 1000 gallon leach pits. .._.. ----------------- 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 po eration until a Certificate of Compliance has been issued bv the board oh health. Signed -- - ---- -------. L --� ----- ----------------_ ----11�0/ 2----------- �- j �Da Application Approved By -------- ----------------- -- -------- -1-------. r..--.`"' ff- �� -�'�� 2"e � Application Disapproved for the following reasons- ------------------------------------------------------(------------------------------------------------------------------------------ ---------------------- - --------- ----------- / Da[e Permit No. � �.----.- Issued -__..-/- - �------- bare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Contplinure THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( XXX J P.Macomber Jr' , by----------------------------------------------------------- --- ------------------ -------- ------------------- ---------- ------------ ..............----- ----------------------------- Installer at -----3606----Route 6A Barnstable. ----------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code/fas described in the application for Disposal Works Construction Permit No. dated __- /'.-. _—_7 Z THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIISFnACTORY. DATE ---------------- -fir-- L--------------------------------- Inspector -------- - --------•--------_--------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE..$ 30.00. ... No.............. .- ------..... Disposal Vorks Tonstrurtion rrrmft Permission is hereby granted J.P.Macomber--Jr.------------------------------------------------•- ------------ ------------------- to Construct ( ) or Repair (X) an Individual Sewage Disposal System at No....�bOC,_.Route bA Barnstable f ------•------•---•-------------------•------------...--•----------••• ---•----- .. Street as shown on the application for Disposal Works Construction Permit �'_ ----- ............................. Board of Healtt DATE------ "<� .. ��----------•-----••-- - FORM 36508 HOBBS R WARREN.INC..PUBLISHERS No.... .7^ •d�- Fas THE COMMONWEALTH OF MASSACHUSETTS* BOARD OF HEALTH ........... ..�W.iJ.......-..OF....... 17 " - �- ...._................... Appl ration for Disposal Works Tonotrudion 11Prntit Application is hereby made for a Permit to Construct (l,.) or Repair ( ) an Individual Sewage Disposal System at: ..............• �, , r n ,�i_..Lo�i�-Address......---•---.........----........_ ......................................................or Lot No.. .... .......................... (J C_iY�l 1 Owner Address ..........................».«.»..».... W Installer Address Type of Building Size Lot... ....+3� a Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ) aOther—Type of Building ............................ No. of persons............................ Showers ( ).— Cafeteria `) d Other fixtures :.................... a( ............ W Design Flow.........1..l.D 11.0........................ per iepesci pgr dray. Total d�il flow---.......__._ .`.3.�_.... .-....gallons. WSeptic Tank—Liquid capacity.I�.gallons Length..1Q.-Lp.-.. Width:.S.•. ..... Diameter:............... D th... ..4-... x Disposal Trench—No. .....................Width....................Total Length.................... Total leaching area. ................... ft. 3 Seepage Pit No.........t.......... Diameter.....14f:?....... Depth below inlet....... Total leaching area..a a,0.sq. ft. Z Other Distribution box�) Dosing tank ( ) ✓ a Percolation Test Results Performed by....QPN J-....CAP6...... ............. .... Test Pit No. I................minutes per inch Depth of Test Pit...(..�q�-. Depth to ground water.. -... . . . e . f� Test Pit No. 2..��minutes per inch Depth of Test Pit...1 .�2_ii.. Depth to ground water..._. Al ................. .s .......................... ... ....... . . ..6. U'tt. ............... ........_.........--t<..... �vh O D ription of.Soil . r .. .. wGjx.- V ..C.,T • • ........... Z L. Agreement: �l►� _ e.443 . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLZ 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................................................•-•---••......••--•...........•-•..... .......................... Date Application Approved B .. ^ ^""'{- ...................................... Date Application Disapproved for the following reasons:..........................................................................................................._»» ...-•--•----•...................•--------•----------•...-------------•--------.....-----..................--..__.....................----•-........•--.........--•--•••••.............................._ Date PermitNo.......................................................... Issued_.................. -•--•---•--................... Date ' THE COMMONWEALTH OF.MASSACHUSETTS a BOARD OF HEALTH L�13t4�! r-......OF......... o� .. :.�.�.. ................................. " (Irrtif irate of Tompliam THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ('4° or Repaired ( ) by...................................................................••---••••-......... -- . --........................... ..-•--................---............ .................. ' Installer at........t .k a•.••.:.. -f-...4.,.A------------_-------•••--• ................................•-• .... - 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...... ..a 1.A.._:.:... dated........................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE. SYSTEM WILL FUNCTION SATISFACTORY. DATE......................................•---••--------................-•.......... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .�:.a�.L(-.- {••c rLrarri .........OF..........1 � ................................ p ..... Disposal Works Tonotrnrtion Prrmit Permissionis hereby granted.....................................................................------..............---:..................................-•--........... to Construct ()<p or Repair ( ) an Individual Sewage Disposal System atNo........ .. .?...`;)........ ....1'��..._�.J9............................... ....- Street as shown on the application for Disposal Works Construction Permit Dated......... ...............•-. U.....� ?. _ Y Board of health DATE...............L� �-C7..-...�.�.................:. No.. Fins. 77 ........... M THE COMMONWEALTH OF MASSACHt^ETTST BOARD OF HEALTH _---.-.--T"(bujo...-......OF....._'9? .-�PS - P5L_e-.............. ........ Appliration for Disposal Works Tatuitnuffun trrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: L,.o((_Tn Z or-F �2r &a- .............. ..........._._.._..._.... _..__ ..._..•. ............._....__._....... ......._................................. •Location-Address or Lot No. W ................ ..._........_. ..----....._...-•--------............. ..---•-•-------------............---.......- ^ ....- ---................. Owner Address .............. a • :. --•-........ - .-• ......... ........•- m Installer Address Type of Building Size Ua Lot.. feet . . Dwelling—No. of Bedrooms............................................Expansion ansion Attic Garbage Grinder (�) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria Q Other fixtures .......................................r,ra_.. W Design Flow..........•I. ........................gallons per person per day. Total daily�iflow .._..........._" ?_Q....._..........gallons. WSeptic Tank—Liquid capacity.I S00_gallons Length..!?:?L!..., Width_._F.a,._ .___ Diameter________________ Depth.. _ ._- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No........_.I........... Diameter.....l zn....... Depth below inlet.......L......... Total leaching area..Z6^_1:.V.sq. ft. Z Other Distribution box (�) Dosing tank ( ) l '-'' Percolation Test Results Performed by.....7�!�? r. l�.�.... �� i -. _I__�_-_O_ _�_-s_ ,al Test Pit 1 o. I................minutes per inch Depth of Test Pit... _nP...... Depth to ground - 'vwater..�. 44 Test Pit No. 2.. ': :__..minutes per inch Depth of Test Pit... �_�.'�_..... Depth to ground water._ -. .. :...�. (.._`........................................... ....�.. � t....:......�.�........ O Descri Description of in ?.�..?4•-rOlp•k•S '.•_ 'Z4 0U-` C,t•0�f C-L A_...._..._. x (��l`)—.................... l•�.. .e i12; 1- "'2e '.l ?;< <..t T`{ G �(_ ^�"— 4,r`'�t fir`.):` `) t�> u U � U c st�T�l-.(t ]n4" U ' Nature ofof R rs=or Alterations Answ"" a when p icable....... W_._ -__ _-_ O . �- ......_. __ ....... ......... .... ... _.. ..Y....... ............................ Agreement: 1 ( �,, �V The i ndersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of U% 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...................................................................................... .........................._.... ..................Date Application Approved By..--•--•--��---`-".:.:..�_�.:�:.: :..:: .�...................................... ..-............... Date Application Disapproved for the following reasons:............................................................................................................. ......--•-----•......................................•-•---.....-•---•--------••••--.........----•---.....-•-----•----•--•--•---•--•-----••--•--•---..................................................... Date Permit No....................... • ...............•-•••-••----_... Issued..•..........-- Date ..-•..........._......--..........-• f_f-, _, . ..-, — -- —.-— — —— -, .-, — — P-. .�,._...- ---: -..-,.- •--— — — -_ —.. THE COMMONWEALTH OF MASSACHUSETTS —�--- BOARD OF HEALTH ---.....7-//sue-._......OF.........{� �aJa` 1f...................................... TW ertif irate of Tomphanre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( )'or Repaired ( ) by................................•-•---..........................•-••.................... -•-....... ............-••............•••••••---•-....................................................... (� �.................. Installer at !� ....._....................^--•-••---.--•--•-•---...............--•------•-•........................... has been installed in accordance with the provisions of TITI—P 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._...R. . ...... ....._.._.... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................................•••...._.•-••............ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........�2-:? �...........OF.......... No... :.............. _..................................... Ft.B..�....^.......... Disposal Works Monstrurtion Vrrmit Permissionis hereby granted..................... .................................:.....•--••---............---.......................................................... I: to Construct or Repair ( ) an Individual Sewage Disposal System at No........=Z e:..7...?L....•.:. __ _I_�_ ............... ....: Street as shown on the application for Disposal Works Construction Permit No... Dated...... , -, . .... y � DATE•............. = 1�a ........................... hoard of Ifealt� s G� No. Fee BOARD OF HEALTH + TOWN OF BARNSTABLE '°' Y 0[ppYicatiou f or Yell Cow5tructiort Permit Application is hereby made for a permit to Construct( j, Alter( ), or Repair( ) an individual well at: { Location-Address Assessors Map and Parcel S Le Me °'M rk„n S--feint wner Address �s�mon.cl v��e�l ��cit�►� � �hc:. P_a .�x ���� ,pr��s ; ��- o�y 3 Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well l Y Y �t (� "S�yb I��(m Capacity Purpose of Well i r r(pja;` ` D n Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certi c to of Compliance has been issued by the Board of Health. Signed. qu Date - Application Approved By., Date Application Disapproved for the following reasons: J c� Date Permit No. 1/v �d � 0 q I Issued 1�2 15 —)LO Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance _ THIS IS TO CERTIFY,that the individual well Constructed,M, Altered( ), or Repaired( Installer at '3'U Q LP M cu n 'Strme�- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. W 20 241— 6N`� Dated f�—/5, 1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH % =~T-O-W-N .0-.F B.ARNSTABLE - Zertifficate of (Compf iance - THIS IS TO CERTIFY,that the individual well Constructed , Altered( ), or . Repaired( ' by �sm a n ci Vv-p, ( O r , i t i y jcf 1 n.c.. . „ �1 Installer at 3 U D LO Moon 'sty-�-,C.. . tar h,I C- b 1-p x has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. 6c4 4 Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE �v 6 NMI Cou9truction Permit No. Fee I Permission:is hereby granted to Installer ' to Construct(�), Alter( ), or Repair.( an individual well at: t� No. 3 l,o D tP M(0" 5A-f e-r— , 6a h-N�b fi e, Street as shown on the application for a Well Construction Permit No. 09 C);() OBI C! Datedr _ �% Q�°` Date- Approved By No. Fee ` / r BOARD OF HEALTH TOWN OF BARNSTABLE 01ppYication jor well. Construction permit Application is.hereb made for permit to Construct� Alter O Repair(pp y p ), or Re air an individual well at: Cx � 3 c�o clr.M r�i n s ram+ , r nsta b it, Location-Address Assessors Map and Parcel ray" p 7�U �t C leery SCV1�Oed�r 3t�n� N�G�n S}iP� Bari 5fu.�'1P, Owner Address Desrnerlra w'et� UIit\YYA 2703 ,&V(A"S o2C�y Installer-Driller Address f Type of Building Dwelling V Other-Type of Building No. of Persons Type of Well l Y ►rl'rr1Gl �?h Ll \SCN�d"I� Capacity Purpose of Well l Y Y l QcLA i on Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. " Signed R+ Date • o . Application Approved By Date Application Disapproved for the following reasons: }r� Date Permit No. !Z d 61,( Issued /` e —)L d Date u ,,.4,w� t i � ".^--,,,,,.,• �- w �7. �_..,,, t as - s t s !^s 12 z / «.<-.mnm.,,..y.w..,.,<...�ti .�w..a,. r+x*.w.aa:u>w.ra>w...--m., ...< ... -. a. -�.>..y.. . .., .. ��• �� ��� '• . �:af -c,:�' d _..y, iv rE - l« • r'< Y R Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal Sy- jL%m Ff%rdr Asset.;,nests Property Address /^ Ow ner �L_�..✓��I/1 C information is OW nets Name -- 630 requiredforevery ✓✓l �q le /� Qa b30 -�, 020 / page. Cityffown �� - rats Zip Code Date of s pact' A . 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 outforms A. General Information filling out forms on the computer, use only the tab 1. Inspector. key move your /P1 cursor-do not use the return key. Name of Inspects 1/10 — i,E G / Company Name Company Address -iVtl �✓� p� `Lf� City1rown State Zip Code Telephone mber 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 �1015.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �n InspectorPs 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. —*This report only aescrlbes 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. t5ns 3113 Tile 5 Official InspecficnForm Subsurface sewage Disposal System•Page 1of17 V i Commonwealth of llllassachusetis lug Title 5 Official Inspection Form Subsurface Sewage Disp6sal System Form -Not for Voluntary Assessments 260 ( �Gl0 Sf- PropertyAddress ON ner information is Owner's Name requiredforevery �G/diS o, /-e Od(0.7-0 R a 0A6 page. City/Town State Zip Code Date of spec B. Certification (c6nt.) Inspection Summary: Check A,B,C,D or E 1 alwayscomplete all of Section D A) Syste asses: 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. Check the box for`fires "no°or"not determined"(Y,N, ND) for the following statements. 9"not determined,'please ex0ain. 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 tflat the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): 16ure•3M 3 Title 50fficial Inspection Form Subsufam Savage Disposal System•Page 2 of 17 A Commonwealth of Massach usetls t le 5 Official I Inspection ecf�®n Form Wj Subsurrace Sewage Disposal System Form o Not for Voluntary Assessments Property Address oaf ner D She O,v ner's Name information is 1� oc R o� required for every A✓A r �C. 0 Z/ page. Clyyfrown State Zip Code Date of4rispe9flon Be 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 ❑ NO(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 mannerwhich 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-313 rite 5 official inspection Form Subsurface Sevage Disposal System•Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Properly Address S�- Owner information is Qv ner's Name required for every 61aV4,S'J, page. Cityrrown State Zip Code Date of spec n Bo Certification (coat.) 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 fbrm. 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 2 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 fl ow, t5ns•3M3 Tft50ffidallnspeclionForm SuUWace Sewage Disposal System-Page4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Roperty Address 36Ob Ow ner ow nets Name information is ,(I requ'vedfor every _ gel✓'�.S T4 � =`l- (9a page. Cityfrown State Zip Code Date of I pec" n B. Certification (coot.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or —/ obstructed pipe(s). Number of times pumped: ❑ L� 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. ❑ 2 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ LJ ny 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 fleet 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 DOD 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.] ❑ e 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 CM 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E7 Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section 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. tans•V13 Title 5Official Ins pectim F art[Subsuface Sewage Disposal S)etem-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Ow o ner Ow nePs Name information is / page. Ta forevery /Town i(S 7, b !e /�/7 �o�6,30 State Zip Cade 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 o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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 WA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? i 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM R 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#.of bedrooms): Ons 3h3 Title50ffidallnspedcnFc=Subsurface Sewage DisposdSys6am•PageSoW Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ' c QN ner ON nees Name information is / required for every 9Qr h S b Ze D.)-6 3o 8 d o L page. Qyrrown State Zip Code We of Inspec' n D. System Information Description: / Soo ot'�4f-1��� 4 rf o✓I �C7.� Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(include laundry system inspection El Yes No information in this report.) ,., Laundry system inspected? El Yes IYr No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date� Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: t5 rs•3113 Title 5 official irspect on Form Subsurface Sevoge Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �� ON nets t�larrre � /] information is I / J � /J Da�3c) required for every �►�►'�.S �b/�P �/20 � page. Ci ylrown State Zip Code Date of In pectic D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ' Source of information: Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(descri be): t5ins•W13 1iUe 5 official Inspection F arm SuWoace Sexege Disposal System•Page Sof 17 Commonwealth of Massachusetts lug Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3606 Property Address /��t " Owner � ` ��.Q`• information is ey Ow nef's IVartte �o�6�Q requ�edforev �/✓),S a .p � page. 5RFow n e Stat Z'�Code Orate of Inspectio D. System Information (cont.). Approximate age of all components, date installed(if known)and source of information., bl Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer pocate on site plan): Depth below grade: feet Material of constructi;'40 El cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Maten construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: year Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No C X (a Dimensions: ?!� Sludge depth: t`ns-3H 3 Title 5 Official Inspection Form Subsufaee Sewage Disposal Sysl am-Page 9 of V Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address - Ow ner information is Ow nees Name / required for every ✓yl$ �c h/C ��� ( a d �� page. Cdy/Town State Zip Code Date of Inspec n D. System Information (cunt.) Septic Tank(cont.) Distance from top sludge of sl a to bottom of outlet tee or baffle Scum thickness / — `� C4 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle E0 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.): kt14 ✓y ,h 4011 ✓)-tee�-�� � l a�^ � g�, c' 7� o0 CC��►�i��oH 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 t5ns•3N3 Title 50Fficial i spection Form SubsWace Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments //Y4 fill Property Address ON ner ON nees Man*infornmfion is J s (� � ? requ�edforevery 0 P/C)C)/4 page. C ityfrown State Zip Code Date of Inspecdon D. System Information (cost.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? Yes No t5rrs•3113 Title 5 Official InspecficnForm Subsurface savage Disposal Spwm•Pge 11 d 17 F' I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Cw ner Cw ner's Name y� information is G✓h,f�5� 1 /14 '�D L j?" 9 op-6 �6 required for every page. Qyyfrown State Zip Code Date of Wspection D. System Information (cont.) Distribution Box (f present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): x sd l, j ZA 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: t5ns•3r13 Tide 5official Inspection Form Subsurface Sewage Disposal System Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Font -Not for Voluntary Assessments Property Address Owner ow ner's Name information is required for every _ ���STD �K page. c�tyRtnwn State Zip Code Date of Inspection D. System information (corn.) Type: 6 leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow`cesspool number. ❑ innovative/altemati%e system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): v Gvw �► rt Cyr 61 *�-- n7c 110, No �SI 15�t ti ��uw 1, 1,4 . 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 t5rs•3M3 Tile 5Official Inspection Form SuUWace Sewage Disposal System-Page 13of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Plot for Voluntary Assessments 260f, 1 Property Address - ' al,ner infom>ation is Olry ner's Name required for every G✓N S �! f o �011,6 page. Olylrown P � �O o ` State Zip Code Date of 1 s n f D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I 15ns-W13 TWe50fficia11nspec ficnFart[SubsurfaceSew age Disposal Sim,Page 14 of 17 ILI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address l/l la 1 1/7 S � Owner Owner's N Sh e ame N information is / / required for every ✓t� $'7-G �L( /¢ Oct 6�� Y o?o page. City lTown State ZP Code Date of l s Ron D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two rmanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below. ❑ hand-sketch in the area below drawing attached separately Mine 3M3 Title50tficial InspectionFom[SubsufamSeviageDisposal System,Page 15of 17 Ili f Commonwealth of Massachusetts quo 2606 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address oN ner ON 2� information is ner's Name7; _/ // required for every G✓�$ T4�O ()� C 30 15, o Page. City�ow n State 11,6 Zip Code Date of hspecflon D. System Information (cont.) Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth t igh ground water: feet Pleas dicate 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 aI Board of Health-explain: -fed — nAj ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: r You must describe how yo established the igh gro nd water elevation: Mo ✓`1 17 p 2 e ps ! Before filling this Inspection Report, please see Report Completeness Checklist on next page. t5ns-3M3 Tits inspecdon Form Subswace Sevage oisposai System-Page 16 of 17 Commonwreaffh of Nlassachuse4ts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l� Address 26 0 6 , 11%1 ONnerinformabonis Mqu page. P iptate � C,�0 �Page. C�yRcwn r Ewe of � E. Report Completeness checklist L7 inspection Summary:A, B, C, D, or E checked mspection Summary D(System Failure Criteria Applicable to All st S Y ,,,,,� ems)completed 2 Sy ern Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate fie 4 - r , '�13 rMOSOMOM BSPSOMFom[Sub3WaW SerageDWpMJ System'Page 17 of 17 Page 10 of 1 I OFFICIAL INSPECTION FORM.NOT FOR VOLUNTARY A SESSANTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F PART C FORM SYSTEM FORMATION(continued) Property Address: 3406 Maln 4rreet Barnstab! bAA pa Owner: Mary D;�a, Date of Igspection: November I7 Anne i SKETCH OF SEWAGE DISPOSAL SYSTEM benchmarks. Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or Locate all wells within 100 feet. Locate where public water supply enters the buildin _ g i 9AU a 1 A A 6 ' a i yy a y s 1 (y� a 3 �S -7to yoZ 30 �Co�e�f i / I i 10 i Commonwealth of Massachusetts U. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments o & 1v1414 ,5,L- 6_1� Property Address �auri�e- O9s4eo, Owner Owner's Name /{ /� / Information Is _ D�bJ required for _ dally)jr._.._._. _.-- --._ every page. Citylrown State Zip Code Date of lnspedUon 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 A. General Information I forms on the 0 zC) computer,use 1. Inspector: - s only the tab key ✓ /sue /� to move your k e the return Name of Inspector � Company Name �� Company Address City/Town State Zip Code 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: Passes ❑ Conditionally Passes ❑ Fails (771 Needs Further Evaluation by the Local Approving Authority _._ d / , Inspector's Ignature 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. C) Ons•11110 rde 5 oNk Forn:ftbsOme Gow"y"DWp*W$yvWm•Pqp t or I? I— r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address Owner owner's Name // information is c_r yr S?u 4�� _ /��9 o_a 6 30 required for _ _ every page. City/Town State Zip Code Date qff inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) Syste asses: 7I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): One•11/10 Twe 5 Olridal Wgmd w Form:Subsudf w SWAUG Disposal System•P20 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 20 Property Address , 1 .SA — Owner Owner's Name �// // ' Information is // ✓s7 5 TR b�� 1"'1 Od 6f0 9 oZ 7 / required for -- every page. City/Town State Zip Code Date of Irlspecti n 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 ❑ 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 16.303(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 emns•11/10 Me 5 Of el InspooWn Form:SubsurAsc*Sswepp Wposal Syslwn•Papa 3 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form zi Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address I information Is Owner Owner's Name /''�required for .._._ _ _.____ Z k every page. City/Town State Zip Code Date o inspec n . B. Certification (cunt.) 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 aseptic 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 wells*. Method used to determine distance: s. 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 ❑ E9 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 Ons•11/10 TWe 5 Oftal I nspekAlon Form:$ubwkha Sewage Dh�8ykom•Pap 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address i S�e Owner Ownet's Name Q Information is j/ /� Dp� 3a / a 914 required for — every page. City/Town State Zip Code Date of inspection B. Certification (cont.) Yes No ❑ �/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ' ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ L7 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ Q/ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 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 16,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section 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-1 v10 TO 5 0MC181 lrapeeM Form:SubsurfaN Sawapa Dlep O Syetam tape 5 of 17 i Commonwealth of Massachusetts WEEM Title 5 Official Inspection Form C Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - Property Address O Owner Owner's Name Information Is �h S-�a h�Q �,4 oo)630 _4LIpec2onregWred for —• ---every page. City/Town State Zip Code Date C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No Q/ ❑ 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? l� ❑ 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? L�J ❑ 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 u 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: , L^J/ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)) D. System Information Residential Flow Conditions: ,c— Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Jra Ong•11/10 Title 5 Oltictel Inspection Form:Subsudow Sewspe Disposal System•Peps Oct 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �GO /41A1✓► s2' __ Property Address Owner Owner's Name �d W / o�intormatlon Is �b/� A�') required for State Zip Code Date o 'nspe n every page. City/Town D. System Information Description: � c __ �� `•/ l Number of current residents: -/ --- Does residence have a garbage grinder? ❑ Yes ©�No Is laundry on a separate sewage system?[if yes separate inspection required] : ❑ Yes [-IN—o Laundry system inspected? ❑ Yes R rvo Seasonal use? ❑ Yes 20 u✓i'ew yL Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? '- ❑ Yes R— to / Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gagons 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: t8lne•11H 0 Title B Otlioiel Inspeetlon Form:subsurfeoe sewepo owpoeel 8ydem-Peps 7 a 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments ZeT0 Property Address Owner owners Name Information Is / A( 19 30 c)� / G�' S T�i Q required for Cnyn o — state Zip Code Date of 1 spectl every page. wn D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: -� y Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons x How was quantity pumped determined? Reason for pumping: Type of S stem: 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): Ores•t uio Me 5 ondai bsp®cdon Form:subwdaw Uwap Dis sysbM•Papa a of IT Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address Owner owner's Name /�j Information iZ'1e15-4"i �� / !4 od 6 17 o�7 1 required for -- every page. CltyPrown State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installe if k wn) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;'40 . /0 -- ❑cast iron PVC ❑other(explain): l Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): l/ Depth below grade: feet Materi f construction: concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list.age: years— Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 7 ` tsira•11110 TWO 5 Official Inspectlon Form:Submiloce Sewpe Disposal system•Papa 9 or 17 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address (� 4 Owner owner's Name �I F, 1 / q n Information is �G/N S 7`+� // ' // Ooi b 30 " / O?/ required for - State Zip Coda Date of I ectlo every page. City/Town in D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle --- Distance from bottom of scum to bottom of outlet tee or baffle o e A 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.): ILI Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑lmetal ' ❑fiberglass ❑ polyethylene ❑other(explain): x 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 gum-11/10 TW9 6 OftWI Inspwdm Form:SubaurfwA Sawapa Dlspose Sysbm•Papa 10 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection. Form : a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address O ' '�ie� Owner Owner's Name information is /!e- � G (�,required for every page. CitYfrovm State ZJp Code Date of napecdon 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: r I ❑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: r Date Comments(condition of alarm and float switches, etc.): ` t r '1 "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No trine• vt o Title 5 OftW Inspedion Form:Subsudwe Sewspa Disposal System•Pao it of 17 . I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 26 0,6 -�Ala 0:1 _,�Y - Property Address / Owner Owners Name i Information Is required for CState Zip Code Date of ecuory every page. C41-town D. System Information (cunt.) Distribution Box (if present must be opened) (locate on site plan): z— kP t--i Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): ----�b !e ve —_ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 1SIM•11/10 TMIe 5 Official Inspection Form:Subaurfeee Sempe Disposal$Y*n'Pago 12 of 17 - 1 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewace Disposal System Form-Not for Voluntary Assessments Property Address II Owner Owner's Name el is724required for b o)630 every page. Cky/Town State 7jp Code Date of Inspectl6n D. System Information (cunt.) Type: STO ti,� leaching pits numberCd ❑ 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.): off r✓1 _ i� �/ � � O _A hove , 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 — • s •. Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No . t5ins 11/10 Tft 5 OWW Mpod im Form:Stftudwa Sowape 04NW Sy*m•Pop 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address / Owner Owner's Name Information is � / A,� required for G✓N _- C—�— every page. Citylrown state Zip Code Date of In cdon D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.), t tstru•,v,o �LN Commonwealth of Massachusetts 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner owners Name Information is Oro sl a �� AQ�(,moo _ required for State Zip Code Date of I eodon every page. City/Town 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: ❑ and-sketch in the area below drawing attached separately 40, C" . t t5ins•11110 TM*6 Official Inspection Form:Subsudaee Swap D*mW System•Paps 15 of I? Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address � � S�e�, ��'�_ • Owner Owner's Name I ([ Information Is �G rv1 S7 Q s It /A / 6b2 610 9 a r required for State Zip Code _ Date of I pectin every page. Cltyrrown D. System Information Site Exam: Chock Slope ❑ Surface water ❑ Check cellar y ❑ Shallow wells �J Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: r ❑ Obtained from"system,design plans on record ' x If checked, date of design plan reviewed: Date ❑ bserved 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: �` k You must describe how you established the high ground water elevation: (,✓� T /f!�► c ?o f f ! W ✓I(%L✓c e�E Before filing this Inspection Report, please see Report Completeness Checklist on next page. - , Ons-11/10 Title S OMcfal Inspection Form:Subsuncoo Swvaao Disposal System-Pop 18 O 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address Owner Owners Name �N f 7`c h to / ✓� ` (�a� 0� o� Information is required for every page. City/Town State Zip Code Date of Inspecton E. Report Completeness Checklist 3--in'spection Summary; A, B, C, D, or E checked (inspection Summary D (System Failure Criteria Applicable to All Systems)completed L� Sy m Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file x t5ins•11110 Title 5 Official lnspeftn Form:Subsurface Sewer Obpwai Syelam•PaV 17 of 17 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address: 3606 Main Street Barnstable, MA Owner: Gary Disarclna s Date of Inspection: November 17. 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. m a a-7 S a r F 10 o �.. 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