Loading...
HomeMy WebLinkAbout3660 MAIN ST./RTE 6A(BARN.) - Health 3�6607AIN�STREET/RT. 6A, BARNSTABL A= 317 021.001 SAW }�o A wb c ASHLEY MANOR-- OOTT Gr; - A .N to i e F 1 f !s .2 - 9 f i 9 i} r� 1 �l /S 3 No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpptitatlon for Disposal 6pstem Construction 3pPrmit Application for a Permit to Construct( ) Repair()( Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. _3G(po t4A 10 57" SARV. Owner's Name,Address,and Tel.No. V I iv ewT TOP,6NJO Assessor'sMap/Parcel �1� Qa� ©p � C I Installer's Name,Address,and Tel.No. S O$-16'1-1 $$77 Designer's Name,Address,and Tel.No. Ca�� W-r�0&6% N .1 is s-�- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building B55 i®fV'T`l4(. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) y gpd Design flow provided Ad& gpd Plan Date �T Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Read (-IIJE- RULC 607-C r eP SGVTaC Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ;�0t " ( �" Date Issued Is--(—(� 4 No. d Fee J THE COMMONWEALTH OF MASSACHUSETTS Entered;ncomputer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes `- 4plication for Mfsposai 6pstrut Construction 3dermit :l ='Application for a Permit to Construct`( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 3( W MA(A)S?' aAt;V. Owner's Name,Address,and Tel.No. V i lva'a sT TO;ZGNO Assessor's Map/Parcel 31'7 Oot d o o 3GkO AlkUd G gam" Installer's Name,Address,and Tel.No. $01&-tom!?—9977 Designer's Name,Address,and Tel.No. Cs3 <ADMju�r�e2�ses &W59* Nl� Type of Building: Dwelling No.of Bedrooms P /✓') Lot Size sq.ft. Garbage Grinder( ) o Other Type of Building 9E5 08C)IT 144—, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A1' A- gpd Design flow providedd Plan Date 1 Number of sheets Revision Date It t gp Title Size of Septic Tank Type of S.A.S. _ Description of'Sod I Nature of Repairs or Alterations(Answer when applicable) REhAr_6 QPLC' RtcyLG oarcCr OP 56-rriG 4&)e_ TD D-12oaG >vL t�J Za cyG L� tTt-F eSe- - y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe O Date Application Approved by cl ` Date Application Disapproved by Date for the following reasons Permit No._f� j '�� Date Issued - ---------.----- . l n r Pp�I✓ u h�X THE COMMONWEALTH OF MASSACHUSETTS I - BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by eA�1^�Ut�S at &AtO ek! G A) has been constructed in accordance r with the provisions of Title 5 and the for Disposal System Construction Permit No. ,?.,( 7- K gated Installer ��1pC� ��' � & g L<Ag-� Designer U #bedrooms lU Approved design flow AJ gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 5-/J0//-7 Inspector ---------------------------------- ------= No. 6 —>` Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS misposal. *pstem Construction permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at 3"D AlA t u 5-r i iQ 6A) and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construot�on must be comileted within three years of the date of this permit. r' Date r Approved by �� �� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH FO.4i�� OF........ Appliratinn for Mipwia1 Mirkii Tomitrurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (K-) an Individual Sewage Disposal System at: ............ .a..........A& :..(AZA----=- , -sue .. ...._..._ Location--Address or Lot No. ----- ...................... ..... ..*.—Ay........ A/..-•-....--••.................. •---•.---•----------------------•------ .....--------....--••--...........................--- gWner Address 1. ---------------•- --........------. ---.....--------------.......-•--------.... Installer Address Type of Building Q� Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------Q---------------------------------Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ............................... . . WDesign Flow.........................:..................gallons per person per day. Total daily flow............................................gallons. fy Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----­-------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by.......................................................................... Date...................:-----------•------- ,aj Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---___-_-__-_-_--_..___. P4 •--••--••-•••--•-•-•••--••----------------•---••-•---•••--------•-...........•-•--•......._...------------------•--•------•••-------•-----•-----•-••---.•-•-- 0 Description of Soil................................-....---........--•--•---.........-•---•---•----------------------------------------•-----------------------------------............---- x c, x ................. ...................................... 0 Nature of Repairs or Alterations—Answer when applicable___416-04 ICI..... 15- -------ate. -se,8 Agreement: The undersigned agrees to install the aforedescribed 'Individual Sewage Disposal System in accordance with the provisions of i r� p 5 of the State Sanitary Code— he undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by e o h_- Signed---••------------ - ..._ .......... . ................................... Date Application Approved By..........................-•--------• ---------------- ......... Date Application Disapproved for the following reasons---------------------------------------------------------------•----------------•----------------......••--.-•--- -•----•-------------------•------•---•-•-••-•--------......-••-••••-•----••---...........-•-----•-......... QQ Date Permit No..-----.Q.. :-.. � ............. Issued....................................................... Date No..0._Z 15 Fps....- Ca..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........O F........4 J ......416-.......................... Appliration for Bispunal Works Tnnstrnrtinn ramit "`Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal System at: Location- ddpdrzss or Lot No. ---- /I rer - Address Js----.. C.................... -- ••--...- ,.a Installer Address Type of Building Size Lot-____--•------•---_••---.--Sq. feet Dwelling—No. of Bedrooms........�j(I..................................Expansion Attic ( ) Garbage Grinder ( ) p`�,, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. G: Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth___-________-_-. Disposal Trench—:\Io. .................... Width.................... Total Length.................... Total leaching area------_________---sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit...._............... Depth to ground water........................ •-•..............•--••-----•------•------------•---.................-----........-•-----•----------........................--•-------------------...---•••--- ODescription of Soil........................................................................................................................................................................ x U --------•---•--••-•----•-••---•-•--•---••--------•---------------•---•-----------------•-....-----------•-•----•--••------------------•---••-•---••---•----------------------•---•....._..-------------- W UNature of Repairs or Alterations—Answer when applicable_.Z -/.,Q_ .�_ .�5r� _..__.__3_Y 1` :!.I......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T�� the provisions of 1 f'i� ::^: 5 of the State Sanitary Code—;he,undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ; issub ep ar Signed..............r ......................................... -=......-•-•.................. Date Application Approved BY q", -1 '' ......•--•.. �� -- Date Application Disapproved for the following reasons---------------•------------...---------•------•--------•------------------------•---•-------••-•----------•---- ...--•--•-•----•-•--•------------------------•-----•-----•-...--------•--•-----•••••••--------••--•••-••.••------------------•-•-----•------------•---•-------------------•---------------------••••--•- _ Date Permit No....... ................ Issued.... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a OF..........fl!.4..:.­^ .. Trr#if iratr of Tuntplinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired .) by----------------- -r r ........... ..--------.....-----------------------------------•--...-----•------....----------........------.........---------------- ,� G G r l _ Installer at................................................. ------... —......----✓ram?-!. l'Y ±c_rt-....!. --------•----•---------------•-•--•-••-•--....------------------------------. has been instailed in accordance with the provisions of TIT Z j of The State Sanitary Code as described in the �!application for Disposal Works Construction Permit N o.._ ............. _-_- ...... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... ,- �_.?........................ Inspector--------------------- --------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH S t% ..........- fps...-:, .........OF......... '� �:'............................................. _. a FEE... ...�'... Dispimal Vorkii Tn it udivit antif Permission is hereby granted ..--•--. to Construct,(� ) r epair (�6 an Individual Sewage Disposal System "' ---------------------------------------------------- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ,----------- - V Board of Health DATE------...... ^ ' � �..................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TOWN OF BARNSTABLE 9 . SEWAGE # ! /��4 LOCATION VILLAGE �, d %•'� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ►yC. >'�j (r,: ;; LEACHING FACILITY:(type)s; . TACJrF9(size) !kf r NO. OF BEDROOMS / PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER p 01 DATE PERMIT ISSUED: I DATE . COMPLIANCE ISSUED: 1_� VARIANCE GRANTED: Yes No / =��" �� �� �. � ��F r �. # � r `� '' .� . _ _a , . ,.L0 AT ION SEWAGE PERMIT NO. VILLAGE E,n2NS- c- INSTALLER'S NAME i ADDRESS R U�I L D E R OR W"N ER, t� I V5 sti DATE PERMIT ISSUED DATE COMPLIANCE ISSUED LOT NO. : ADDRESS d OWNERS NAME: Akac\ SEWAGE PERMIT NO. : NEW: REPAIR: DATE ISSUED: DATE INSTALLED: ,! `INSTALLERS NAME. cAv\�leu I INSTALLATION OF: WATER TABLE : FINAL INSPECTION BY: DRAWING OF INSTALLATI- . bra REVERSE SIDE : rhA•� s cr- 9S� 1�©® Gal, rgVAK ZOL<'ATION - SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS e U I L D E R OR OWNER, l s�� DATE PERMIT ISSUED i DATE COMPLIANCE ISSUED - F Z ' G 0 i y3 1 r p m In w 3 r y3 z �a d r 93 i • - TOWN OF BARNSTABLE o LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP a LOT ' I INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ,yC LEACHING FACILITY:(type)W f•.. •+'r.4c,rF#(size) �• .�Cf,0 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER E-2 A,11 G DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I f ro t 4i - I a } L Commonwealth of Massachusetts P Title 5 Official Inspection Forms Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 4 . . 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor . Owner Owners Name /information is every Barnstable V required for eve MA 02630 11-14-19 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. OF Important:When A. Inspector Information filling out forms P a on the computer, z�� JA M ES N" use only the tab James D.Sears = key to move your Name of Inspector cursor-do not Ca ewide Enterprises use the return key. Company Name •. . .. �G ``\�. 153 Commercial Street �a„st ICI Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 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 CM 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 11-14-19 spector'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 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. 15insp.doc•rev.M6I2018 Title 5 OHidal InspedDri Form:Subsuftoe Sewage Disposal System•Page 1 of fa 6 abed R3 dH L2:66 61,0Z e2 AON. Commonwealth of Massachusetts Title 5 Official Inspection Form ii; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �Z 3660 Main Street (Rt 6A)( Main House System)- Property Address Ashley Manor Owner Owners Name Information is required for every Barnstable MA 02630 11-14-19 page. Clty/Town 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. l Comments: The system is a 2500 Gal. Tank D Box and pit. 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,rN, 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 Z a5ed xej dH L2 61, Me ZZ AON Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lug,;;- 3660 Main Street (Rt 6A)( Main House System) Property Address . Ashley Manor Owner Owners Name Information is required for every Barnstable MA 02630 11-14-19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms 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.7/26/201 B Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 £ abed xeJ dH LZU 6 60Z ZZ ^oN Commonwealth of Massachusetts rTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �1 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner Owners Name information is required for every Barnstable MA 02630 11-14-19 page. City(Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must,indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.712 612 0 1 8 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 4 of t8 ' {, a5ed xeJ dH L24 6 6 60Z ZZ .AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F<, 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner Owners Name information is required for every Barnstable MA' 02630 11-14-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any.portion of a cesspool or privy is within a Zone 1 of a public water supply well ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that,no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. El ® 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 C.A. 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 15nsp.dcc rev.7126/2018 Title 5 Official Inspection Fo m:Subsurface Sewage Disposal System°Page 5 of nB g abed xed dH LZ 6l 660Z ZZ AoN r J A ' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3660 Main Street (Rt 6A)(Main House System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page. City/Town Slate Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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)] t5irmp.doc•rev.1/2612018 Title 6 Official Inspection Form:Subsurface sewage Disposal System•Page 6 of 18 9 a5ed xeJ dH R41, 61,0Z e2 -AON Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner Owners Name information is required for every Barnstable MA 02630 11-14-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 8 Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880 Description: 2500 Gal. Tank D Box and pit. Number of current residents: NA 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2018-136,000Gal Detail: 2019-111,000Gal's Note:Water usa a is For Main House and=Cotta e. Sump pump? ❑ Yes ® No Last date of occupancy: Present Date i5nsp.doc•rev.712SI2016 Title 5 OfBdal inspecton Form:Subsurface sewage Disposal system-Page 7 of 18 L a5ed xeJ dH 8ZU 61,0Z ZZ AON. 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner Owner's Name information is Barnstable MA 02630 11-14-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.)� 2. Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15,203): Gallons per day(gpd) Basis of design flow (seats/personslsq.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 occupancyluse, Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ' t5msp.doc-rev.7!26J2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 9 a6ed xed dH 9FU 660Z ZZ AON Commonwealth of Massachusetts Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley.Manor Owner Owner's Name rInform equired dfo is Barnstable required for everyMA 42630 11-14-19 page. CitylTown 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: NA 1987 Permit #87 -555/5-2017 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 30"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.): Pipeing is 4"PVC SCH 40. 15inep.doc•rev.7/26/2018 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 9 of 16 6 abed xed did RU 660Z ZZ AON Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner Owner's Name information Is required for every Barnstable MA 02630 11-14-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 18" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2500 Gal. Precast H-20 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness H-20 Cover Distance from top of scum to top of outlet tee or baffle Not Opened Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 18" belw grade w/inlet cover steel at grade. Three inlet tees. No sign of leakage or over loading. t5insp.doc•rev.7126/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 16 ol, abed YPJ dH K:I,6 660Z ZZ AoN Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v y 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): a Dimensions: Scum thickness ' Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.T12512018 Title 5 Ofrical Inspection Form:Subsurface Sewage Disposal System-Page 11 o118 l, a6ed xed dH RU 660E ZZ ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3660 Main Street (Rt 6A)( Main House System) Property Address , Ashley Manor Owner Owner's Name Information is required for every Barnstable MA 02630 11-14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present:, ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required), Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 26"below grade w/one line out. Box is New 5/2017 wlcover at 4" below grade. ISinsp.doc-rev.7.2612018 TAIe 5 Mial Inspection Form:Subsurface Sewage Disposal System•Page 12 0:18 t Z abed xed dH 6EU 61.0E ZZ AoN Commonwealth of Massachusetts p Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 3660 Main Street (Rt 6A)(Main House System) Property Address Ashley Manor Owner Owner's Name Information is required for every Barnstable MA 02630 11-14-19 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: 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 Typeiname of technology: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 4 £I• a6ed xeJ dH 6241, I. Ao 6 OZ ZZ N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner Owner's Name Information is required for every Barnstable MA 02630 11-14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 1000 Gal. pit's stacked. Pit at 38"below grade wlsteel cover at 4"below grade. Level In pit at 6'below top of pit. No sign of over loading. 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.): 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 b abed xed dH 6Z:1,L 61,0Z ZZ AoN Commonwealth of Massachusetts Title 5 Official Inspection Form WSubsurface Sewage Disposal System Form - Not for Voluntary Assessments � ✓ 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner Owners Name information is required for every Barnstable MA 02630 11-14-19 page. Citylrown 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.): J 15insp.doc•rev.MEMO Title 5 Official tnspection Form:Subsurface Sewage Disposal System•Page 15 of 18 5 abed xed dH 6Z:61, 660Z ZZ AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all weils 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 seperateiy t5insg.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page is of 18 g abed xed dH 6ZU 6 60Z ZZ AON � - ) 6 � w' Enter rises 508-477-4977 .18 Nav 0719,04�33p Capa ide p p Jun 02 2017 MOO FP Faye pace 32 I7��N BACK ` A S /£ £� r O � o 8 7"0 e vv£� �(' -- ° J I R A T C � J la•I - 43 �Q� R Q. c 08 m. L6 abed xed dH 6Z:66 660Z ZZ ^ON ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. �.� 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor -- Owner Owner's Name information Is required for every Barnstable MA 02630 11-14-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑' Shallow wells 20'+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Y ❑ Obtained from system design plans on'record If checked, date of design plan reviewed: Date ® Observed site (abutting propertylobservation 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: Paper work on file w/B O H 20'+to no G W Bottom of leaching around 15' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. tSinsp,doc•rev.7/2612018 Title 5 official Inspection Forth:Suosurface Sewage Disposal System•Page 17 of 18 g 6 abed xeH dH 62:1.6 6 60Z 2e AoN Commonwealth of Massachusetts Title 5 Official Inspection Form 'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U. 3660 Main Street (Rt 6A)( Main House System) Property Address Ashley Manor Owner owner's Name information is required for every Bamstable MA 02630 11-14-19 page. CitylTown 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 IS: Explanation.of estimated depth to high groundwater included t , 15insp.doc-rev.712612018 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 18 or 18 66 a6ed xeJ dH 06:66 6I.0Z ZZ ApN -� Commonwealth of Massachusetts 3/7 pal-601 : Title 5 Official Inspection Form S - 1 r Disposal System Form •Not for Voluntary�� Subsurface Sewage p y Assessments 3660 Main Street(Rt 6A)(Cottage System) r. Property Address Ashley Manor Owner Owner's Name information Is 02630 11-14-19 required for every Barnstable MA r,.'. page. CitylTown 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. 10p,NuuUrl1/l,�i •'� OF MA Important:When �! /(,/ �`�_�� •�9 '�. p A. Inspector Information � - filling out forms � on the computer, = JA M ES :m use only the tab James D.Sears - key to move your Name of Inspector cursor-do not Capewide Enterprises use the return g,�� .• '� — key. Company Name ��4i, 5 INS? EG 153 Commercial Street arnrinunl�`''�� Company Address Mashpee MA 02649 CitylTown State Zip Code 508-477-8877 S1623 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 11-14-19 ;Spector'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 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. i t5insp.doc•rev.V2612018 Title S Official Inspection Form:Subsurface Sewage Disposal5ystem•Page 1 of 18 OZ a5ed xeJ dH 0£:1,1, 6l,0Z ZZ AON Commonwealth of Massachusetts VTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VI _3660 Main Street(Rt 6A)( Cottage System) Property Address Ashley Manor Owner Owner's Name information is reequiredquired for every Barnstable MA 02630 11-14-19 page. City/Town 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: The system is a 1000 Gal.Tank and pit. 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.7/2612018 Title 5 Official Inspection Form:SUbsLrface Sewage Disposal System Page 2 of 18 6Z a6ed xed dH OEU ME 2E AON Commonwealth of Massachusetts w� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3660 Main Street(Rt 6A)(Cottage System) Property Address Ashley Manor _ Owner owner's Name information is required for every Barnstable MA 02630 11-14-19 per. City/Town 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 ❑ 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 ❑ NO (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: Wnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsulace Sewage Disposal System Page 3 of 18 ZZ abed YPJ dH 6E 66 660Z ZZ AoN Commonwealth of Massachusetts r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 3660 Main Street(Rt 6A)( Cottage System) Property Address Ashley Manor Owner Owner's Name information is required or every very Barnstable MA 02630 11-14-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is Within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must Indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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.7l26l NS Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 18 £Z a5ed xed dH 1•£:6 6 6 60Z ZZ AoN k, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 3660 Main Street(Rt 6A)( Cottage System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page, Clty/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth 1n cesspool Is less than 6" below Invert or available volume is less than 'A day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation, ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ The system fails. I have determined that one or more of the above failure®' criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. r I 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.7I28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of!8 c bZ abed xe:1 dH ZE:L 6 6 60Z ZZ AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 3660 Main Street(Rt 6A)(Cottage System) "Y Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page. City/Town State Zip Code Date of Inspection C. Inspection SUMMalry (cont.) If you have answered ''yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® Have large volumes of water been n 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 NIA) ® ❑ 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)1 15nsp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 gZ abed xeJ dH ZEU 61.0Z ZZ AdN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments .W 3660 Main Street(Rt 6A)(Cottage System] Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630. 11-14-19 page., Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal. Tank and pit. Number of current residents: 0 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 Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2018-136,000Gal g ( y g (gP ��' . 2019-111,000Gai's Detail: Note:Water usage is for main house and cottage. Sump pump? ❑ Yes ® No NA Last date of occupancy: Date t5insp.aoe•rev.7/26/2018 Title 5 offlcial Inspection Form:Subsurface Sewage oisposel Syslern Page 7 of 18 92 abed xed dH ;Z£:66 660Z ZZ AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3660 Main Street(Rt 6A)(Cottage System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11.14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to; Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.MUMS T41e 5 Oftal Inspection Forth:Subsurface Sewage Disposal System•Page 6 of IS Lz a5ed xed dH ££:6 6 6 608 ZZ AoN Commonwealth of Massachusetts o Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 3660 Main Street(Rt 6AX Cottage System) Property Address Ashley Manor _ Owner Owner's Name Information is required for every Barnstable MA 02630 11-14-19 page. City[Town State Zip Code Date of Inspection D. System Information (cunt) 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 20 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.): Pipeing is 4" PVC SCH -40. tSinsp.doc-rev.7/28/2018 Title 5 Official Inspection Form'Subsurface Sewage Disposal System-Page 9 of 18 gZ a5ed xed dH EE:1.6 660Z ZZ AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3660 Main Street(Rt 6A)( Cottage System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page. City/Town State Zip Code Date of lnspedlon D. System Information (cont.) 6. Septic Tank (locate on site plan): 8" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 8' below grade. Inlet tee. Outlet baffle. No sign of leakage or over loading. R 15insp.doc•rev.7/26/2018 Title 5 Ofridal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 6Z a6ed xeH dH tEU 660E EE AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C 3660 Main Street(Rt 6A)(Cottage System) Property Address Ashley Manor Owner Owner's Name Informatirequiredo re Barnstable f MA 02630 11-14-19 required for every page. Cltyrrown 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: oats Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): B. 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.712612018 Title B Official inspection Form:Subsurface Sewage oisposaf system-Page 11 or 18 0£ a5ed Xed dH 1;,EU 660Z ZZ AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C� 3660 Main Street(Rt 6A)(Cottage System_) Property Address Ashley Manor Owner Owners Name Information is required for every Barnstable MA 02630 11-14-19 page. CityfTown State Zip Code Date of Inspection D. System Information (cant.) 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 No Box Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): t5insp.doc•fav,7126=16 Title 5 Official Inspection Form:Suburface Sewage Disposal System Page 12 of 18 �£ e5ed xed dH tEU 6602 ZZ AoN Commonwealth of Massachusetts Title 5 Official Inspection Form It Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3660 Main Street(Rt 6A)(Cottage System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* a 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): 6 If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches . number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-ray.712612018 Title 5 otfidal Inspection Forth:Subsurface Sewage Disposal System•Page 19 of 18 Z£ a6ed xed dH b£:66 61.0Z ZZ AoN Commonwealth of Massachusetts p Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l; qu 3660 Main Street(Rt 6A)(Cottage System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit. Pit and cover at 16"below grade. 4"water in pit wlno sign of over loading or solid carry over. 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.7012018 Title 5.01%cial Inspection Form:Subsurface Sewage Disposal System-Page 14 o113 ££ a6ed xed. dH VE41, 660E EZ AoN Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rp 3660 Main Street(Rt 6A)( Cottage System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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.): t8insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 15 of 1S b£ a6ed xed dH 660Z ZZ AON' Commonwealth of Massachusetts Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3660 Main Street Rt 6A)(Cottage System) Property Address Ashley Manor Owner owner's Name --- — — information is Barnstable MA 02630 11-14-19 required for every —.-- —. page. cityrrown state Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet, Locate where public water supply enters the building. Check one of the boxes below; r ® hand-sketch in the area below r� �,;j ronn��AgGb'�CL:AP=.�'iL� r /~ 1Q 0'V j tJ aU �,4 L -'R^'K ar o , 4-rr', 3 3w g6. 13 x9•X ., .7 A•.5 • s_y. rYnla3crtr.9�is M504kigl1"CmnFem:slak^esee qe 4 oikmo$ytble•DtG°3 M v gE a6ed xed did t,6 66 660Z ZZ AoN Commonwealth of Massachusetts ,p Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 v.V 3660 Main Street(Rt 6A)( Cottage System) Property Address Ashley Manor Owner Owner's Name information is required for every Barnstable MA 02630 11-14-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'+ 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 propertylobservation 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: Paper work on file w/B.O.H. 20'+to no G.W.. Bottom of pit at 7'-4"+above G.W.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. tSnsp.doc•rev.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of'8 gE abed xeJ dH SE:I.6 6IAZ Z2 AON Commonwealth of Massachusetts P Title 5 Official Inspection Form ^I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3660 Main Street(Rt 6A)( Cottage System) Property Address Ashley Manor Owner Owners Name Information is required for every Barnstable MA 02630 11-14-19 page. City/Town State Zip Code Date of In spection 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 ti For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included l t5insp.doc•rev.7/2E201 a Title 5 Official inspection Form:Subsurface Sewage Disposal System.Page 18 of 18 L£ a5ed xe:1 dH 5£:C i, 61,02 ZZ AON M TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 5b5-1300 19 Hummel Drive South Dennis, IKA 02660 � COMMONWEALTH OF MASSACHUSET'I'S ir EXECUTIVE OFFICE OF ENVIRONMENTAI,AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION "TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM DART A RECEIVED CERTIFICATION Propert) Address: Ashley Manor FEB 2 1 2001 3660 Main Street,Barnstable,MA Owner's Name: Donald Bain TOWN OF BARNSTAB E Owner's Addres,: P. O. Bolt 856 HEALTH DEP Barnstable,MA 02630 Date of Inspection: February 16, 2001 Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections J Mailing Address: 19 Hummel Drive Telephone Number: South Dennis,MA 02660 (508)385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP appro%ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system V/ Passe's Conditionally- Passes Needs further Evaluation by the Local Approving Authont) Fails Inspector's Signature: Date: 2 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of ► Inspection noted above. •""This report only describes conditions at the time of inspection and under the conditions of use at that time. phis inspection does not address how the system will perform in the future under the saute or different conditions of use. Title 5 Inspection Form 6/15/2000 paee I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Ashley Manor Property Address: 3660 Main Street,Barnstable,MA 02630 Owner: Donald Bain Date of Inspection: February 16, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N//9 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes. no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatine that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page.3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Ashley Manor. 3660 Main Street,Barnstable,MA 02630 Owner: Donald Bain Date of Inspection: February 16,.2001. C. Further Evaluation is Required by the Board of Health: A/ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 supple 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 6 , 3 Paged of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Ashley Manor Property Address: 3660 Main Street,Barnstable, MA 02630 Donald Bain Owner: February 16, 2001 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or c1022ed SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clog_ed 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 '/z 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. HtA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. MIA Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. &4� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system-passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) Nv (Yes/No)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: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page.5 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Ashley Manor 3660 Main Street, Barnstable,MA 02630 Owner: Donald Bain Date of Inspection: February 16, 2001 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _ 1'..;:;ping information was provided by the owner. occupant, or Board of I Laid, _ Were any of the system components pumped out in the previous two weeks? n ova+ `Has the system rec�ived normal flows in the previous two week period? J 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: Yes no Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Ashley Manor 3660 Main Street,Barnstable,MA 02630 Owner: Donald Bain Date of inspection: February 16,2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 8h Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 ��4: � 6�_�e•�y Number of current residents: 2 Does residence have a garbage grinder(yes or no): N- is laundn on a separate sewage system (yes or no): wo [if yes separate inspection required] Laundry system inspected(yes or no): nLAq Seasonal use: (yes or no): No Water meter readings, if available(last 2 years)tsage(gpd)): 60 = 3 22,J�� ,. , �9 : 32ti�oou 9°` fa;'l Sump pump(yes or no): Last date of occupancy: 0 c 4L ,,12, ( 2 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use- OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:'__e,✓.t,� 195�y _— _ ,,,L Was system pumped as part of the inspection(yes or no): AN If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYKE OF SYSTEM �/Septic tank,distribution box,soil absorption system (ND L"rf i. Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe):. Approximate age of all components, date installed(if known)and source of information: ✓Iw... 11n✓fe 5,p ii i > vy.Kn...✓... Were sewage odors detected when arriving at the site(yes or no): 6 I Page•7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ashley Manor 3660 Main Street,Barnstable,MA 02630 Owner: Donald Bain Date of Inspection: February 16, 2001 BUILDING SEWER(locate on site plan) ( fj� k Sy,+..,) Depth belo�k grade: Materials of construction: /cast iron _v/40 PVC other(explain): /t, Dkianc:- fron. private water supply well or suction line: ,v/g Comments(on condition of joints, venting,evidence of leakage,etc.): 1 i.�cs wtic -y'a.,r.✓` -� Icc�r u 4 -j't,.� '1").+1� u�i v. s�-c ��u SEPTIC TANK: (locate on site plan) M�..., Depth below grade: 18" Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: s~ /z 'x Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: .2'/0" Scum thickness: ... Distance from top of scum to top of outlet tee or baffle: 6 �' Distance from bottom of scum to bottom of outlet tee or baffle: / I low were dimensions determined: Pu 6, , Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Z o.,L {y'✓�,� J. _war 1�. «,q ur.At�/,•_/�/a -{�a �... / t-=r .c "L'n.s _.a_/'_i_2—_L_— �. �a.+ i w. '� I�-�J /t/u C✓. w/ c_< /` /�.. t�t-4 S-� O 0. c w.c� oti TV✓ �_eA ..�c ..,c..S GREASE TRAP:,>/w(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Paga 7 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Ashley Manor 3660 Main Street, Barnstable, MA,02630 Owner: Donald Bain Date of Inspection: February 16, 2001 " BUILDING SEWER(locate on site plan),,,,(/_I Depth belo�% grade: Materials of construction: _cast iron _40 PVC_other(explain): Dkiancr fron. pri%ate water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) o F t-z < Depth below grade: /V Material of construction::z/conerete_metal_fiberglass_polyethylene —other(explain) If tank: is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: S 'x 9 'X C , /000 aq,� Sludge depth: 31, -T Distance from top of sludge to bottom of outlet tee or baffle: 02 '16` Scum thickness: /./o�v/_ Distance from top of scum to top of outlet tee or baffle: .410 Distance from bottom of scum to bottom of outlet tee or baffle: /Vo S > •� Ilow were dimensions determined: /",;:L Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): — T vJ/ar �✓/ hw1" O r C'. h ti .c_ W S_f'o.� c.[. /�J e, V �..t c L. �, .�... � L � �r►.i w � chJ�c c.�jJ h. (�wtil'L w4s GREASE TRAP:kLA(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ashley Manor 3660 Main Street,Barnstable, MA 02630 Owner: Donald Bain Date of Inspection: February 16, 2001 TIGHT or HOLDING TANK: '0/9(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions. Capacity: gallons Design Flo\ gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) (M c �t►•Ay,. y Depth of liquid level above outlet invert: S s 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 f.): I /� 19—J- 6;c yjCLIt T�JL-✓- 1N Was�I'L 1. V '� ✓'!Xc✓ U h✓nt 0 tr�1fosoA-y�, 0 it j - 4—, 4p PUMP CHAMBER:A114 (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Ashley Manor 3660 Main Street,Barnstable,MA 02630 Owner: Donald Bain Date of Inspection: February 16, 2001 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain wh3. ( C. JC ti< cw�� �r 4iS'.. Lr._�M's. S . 1 i'J, t iJ`<✓ r NTU i)LID L /�� Cl /1 0- L J',�t v�i.rG ti a.1•t J� ...ti S .r,..tl' •M ..✓ H� .� �rr.c 4 �i..J�e.c c.7j't+i. Tye 2 - G 'X( L p, k-J) ,,,,4 S 'S leaching pits,number: 1 - 6 "X6' t �;:, ;,, t1, s�,,��/ (.J f ►�f . 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.): .44 jo'.f �u� b.i...� ✓ ..� v,d c.-1'�✓ �e� � •it. oYC' �Ukrcr J �- r L k.c S f'z.+. ....�. � .✓ .c rY �< 71rnV�r l < '�jn�.�o r h� 4•:fio. /Vo GU cC�nc � off' c�v-oV1.` / ✓ � f1 -7411—j a.f 'IZ� �j»,.� ° 'C i hS�J-e.c.�j J Y1. t i!✓ /c.6 -r vs. r+. in<�o4.1-P' CESSPOOLS:&L(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 la\'er: Dimensions of cesspool Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY:�(locate on site plan) / Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Ashley Manor Property Address: 3660 Main Street,Barnstable,MA 02630 Donald Bain Owner: February 16, 2001 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water/supply enters the building. A • O �aHw. o. O A� = 46 'A = Si ' A = 53'd'' r = 70 ye 13J = yy' C = yo V, i3r = 37 ' C ot�u�c it, A Frost . uw�t• /600 iKUoti I Afs v.ti eJ iDC..�,ti) IU I Page 1.1 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Ashley Manor 3660 Main Street,Barnstable,MA 02630 Owner: Donald Bain Date of Inspection: February 16, 2001 SITE EXAM Slope Surface water 1 Check cellar Shallow wells Estimated depth to ground water ;C feet Adjusted high ground water elevation .23 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: 7 Observed site(abutting property/observation hole within 150 feet of SAS)(s/.vr Checked with local Board of Health-explain: Checked with local excavators, installers- fffelie Accessed USGS database-explain: j You must describe how you established the high ground water elevation: --_t--o�rV.. „( ,,.i, t •y.e� 3 t'...� .-._.✓ � w«,;.t,� 4 I•�. �.�, �a�iu�•s S f<.... � ) a I s.. :. S�••��G wfl, L.v -f�,y 1 /'t ..(c c. 'ly 'y'2. <�io [.� vZ 3 C/�►bw r, ' �a.a.i ES s r/-a,.., .:�' /�•:c � 1, '� ; s /� ' A„a _ � /� � �-� � ;., -l2< 1, �.-. �..(- hJ..�t�r rLw�..•Mg S Wc�c ub.r-�.h�A7 vw•.. Ar.+� U'1 cY to.'/ PL. Vc-s- (��- PU�v� C,o.�o._ Ef.,y...�.c s.i.•->. ✓ i J 11 THE COMMONWEALTH OF MASSACHUSETTS �BOARD OF HEALTH r4e ......0 F­ /gA#V!�V dL ....... Appliration for Disposal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct or Repair (k) an Individual Sewage Disposal System at: ........... ......... ...(e.#.........ffA4W.. 7511.............................................. . ---------------------- Location,,dddress or E; o. ,00,c,41,0 4 ,V .........................7.p,# .. ................................ .................................................................................... er Address .................. ............................................................................................ . Installer ..... Address U Type of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms........T.............................Expansion Attic Garbage Grinder Other—Type of Building ---------------------------- No. of persons............................ Showers Cafeteria Other fixtures Design Flow............................................gallons per person per day. Total daily flow.... '"...............................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................—'' Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box ( ) Dosing tank ( ) / Percolation Test Results Performed by.......................................................................... Date......­"......****....... Test Pit No. I................minutes per inch Depth of Test Pit....:............... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 9 .................................................................................. ..............*--------- Description of Soil........................................................................................................................................................................ ---------- ........***-------------­­---------"------- ........*"**--*-----------*--------------------**---------*............................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable_...1Z,&V4.4C.Z..... L4—1.r 60'a......(,&r..... 4...... ..................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT LZ 5 of the State Sanitary Code— he undersigned further agrees not to place the system in -anitary Code— operation until a Certificate of Compliance has been issue by edjoyhgalk. r Signed................. . .... .......... . ................................... .......................... % Date Application Approved By.........................I............ .. .... ......�a............... --------- Date Application Disapproved for the following reasons:........................................................................................................ ................................................................................................................................... ............................................................. Date PermitNo......... ............ Issued................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............7f�!. ...OF........... iLn Trrtifiratr of (goutplianu THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.................V.-O ........... ..................................................................................................................... 1� Installer at...........................................I - 5" ........................ "**'*-"**........... ................ has been installed in accordance with the provisions of TI'1E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... ....... .2._�......... dated....._...................._......_......_....._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SfISFACTORY. DATE........................ ........*'"?"**---------------- Inspector.................... ............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . . ............ ....................OF........PPAL No.1.2.......�. ....................................:,"*.....................I................ AsVosal Works Tuoustrurtion famit Permission is hereby granted...........VZ%4,0_`t V* ... --- ... ......*......*....... ---.. to Construct r epair an Individual Sewage isposal System at ANO.............. .............�� ......................................................................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated....._..... ............... ........................................ DATE..............L. Board of Health . ...................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ` ''- �:, may+! l � � c7►1 /Q rZ)`o tir � ���," � 1.� O r V n,u. I / I b d✓b-L- G J 44,5 <- ..✓ c. Th c-•.et !1 U i 4 L 4 c. S J 7/- � o r CIP S / ,..J rp L. 6 �o C_w L L S S�/✓o o w � O G O h.� 7�� L 7,0 ti G ✓ �� � .a`. ,s G i--` � r �h r..s._� O VN N A, C L 5 5/0•,-a / cry �I ti• ( �7�'i fvLo--�iL `7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 3660 Main Street,Barnstable, MA Date of Inspection: Donald Bain February 19, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I NeI-A. 'k s/- 25a6yK//�H • S�pfi�Ta� �ti • 4a �y � 4a '`' 'gDx € € 7 r ' ° ( i i � S 74— (revised 04/15/97) Page f of 10 THE FOLLOWING I S/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) m A- IL F- C&' .DATA LL-IAMS INSPECTIONS X0 tV MA Department of Environmental Protection (508) 385-1300 �garn rtel Drive ulh Den,, MA f}2660 �� COMMONWEALTH OF MASSACHUSETTS l EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �0�� DEPARTMENT OF ENVIRONMENTAL PROTECTION U ONE WINTER STREET. BOSTON, MA 02109 617-292-SS00 WILLIAM F.WELD Govemor TRUDY CORE ARGEO PAUL CELLUCCI Secretary Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM DAVI C B.mTRUHS Commissioner PART A CERTIFICATION Property Address: 3"0 D M 1 •t+ � Date of Inspection: oz./f 9 /cr d Address of Owner: n Name of Inspector: Troy Williams Of different) /' Q 1 am a DEP approved system inspector pursuant to Section 1S.340 of Title S (310 CMR 1S.000) Company Name: Troy Will Jams Septic Inspections �2 Mailing Address: q Hlrmmpl I)rl VP Snuth 1 g s (�A 02660 ""hS 4- Telephone Number. f)P n n ' _f FnQ 1 'tst� '1 znn 6.2 c ?a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes A4 4 ,, / DVS .,.�.,/ cn I f Dh C�+l+,f Conditionally Passes 7 y Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: ���._ h�� A B Date: , The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: __-�Zl have not found any information which indicates that the system violates any of the failure titer' Any failure triteria not evaluated are indicated below. 1a as defined in 310 CMR 15.303. COMMENTS: 81 SYSTEM CONDITIONALLY PASSES: A///g One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If'not determined',explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector w6 a copy of a Certificate of Compliance (anached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (—i..d 04/2s/97) P.9• 1 or 10 BAMWABM NAM The Town of Barnstable Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph M. Crossen Fax: 508-790-6230 Building Commissioner February 23, 1998 Attorney Peter Freeman 3180 Main Street PO Box 578 Barnstable, MA 02630 Re: SPR-094-97 Ashley Manor, 3660 Main Street (Route 6A)Barnstable (317/021.001) Proposal: To legitimize existing B&B with 6 guestrooms, and add 2 additional guestrooms.. Dear Mr. Freeman, The above referenced proposal was reviewed at the Site Plan Review Staff Meeting of February 19, 1998 and approved under Section 4-7.4 (2) of the Barnstable Zoning Ordinance with the following conditions and forwarded to the Zoning Board of Appeals. • Septic system report received and approved by Health, • Easement language noted on plan regarding the electrical service to cottage. • Documentation of history of apartment to be submitted to this office. Please be informed that a building permit is necessary prior to any construction. Upon completion of all work, the letter of certification required by Section 4-7.8 (7) of the Town of Barnstable Zoning Ordinances must be submitted. Also, all signage must be discussed with Gloria Urenas of this Division. Should you have any questions, please feel free to call. Respectfully, Ralph Crossen Building Commissioner 939 main street rt 6a tel.(508)362-4541 yarmouth port fax(508)362-9880 mass 02675 dOWa Cope engineering structural design civil engineers& land surveyors � Ame H.Ojala P.E.,P.L.S. Timothy H.Covell,P.L.S. land court April 23, 1998 David C.Thulin,P.E. surveys Donald Bain site planning Ashley Manor 3660 Main Street Barnstable,MA 02630 sewage system designs Dear Mr. Bain: inspections Pursuant to your request, I have reviewed the design flow capacity of the septic systems serving the Ashley Manor and cottage. I have detennined the following: The permits design flow capacity of the Title 5 system serving the main house is 1660 gallons per day. It is adequate to serve in excess of the proposed 10 bedroom total. The design flow capacity of the Title 5 system serving the cottage is greater than 330 gallons per day and is adequate to serve in excess of the single bedroom therein. Based on the requirements of Title 5 [310 CMR 15.352 and 310 CMR 15.301(5)], no upgrade or change under the new Title 5 is required. Very truly yours, �H OF � OAMA 4-ylt // CIVIL N Arne H. Ojala,PE,PLS Ho.3" Down Cape Engineering, Inc. , �E�fsn-ts ONAL �N6 cc: T. McKean,Health Director, Barnstable Health epartment Atty. Peter Freeman Town of Barnstable Inspectional Services 9 BARNSTAB ��' Public Health Division M ° Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Fax: 508-790-6304 Office: 508-862-4644 = . AFFADAVIT FOR A BED AND BREAKFAST PERMIT EXEMPTION FORM Name of Bed and Breakfast: S h L 6'- Address: Telephone: '.�5— Name of Owner: N/[nf C '6^c-.r Telephone Number: •t5-6 As Per 2013 Food Code, State Sanitary Code MA'Regulations for Minimum Standards for Food Establishment, Chapter X -.105 CMR 590.001 (C)(1) and can be found on website: https://www.mass.gov/rez ulations/105-CMR-59000-state-sanitary-code- chapter-x-minimum-sanitation-standards-for-food I attest I am qualified for a Bed and Breakfast Permit Exemption because I meet the following criteria: Owner Occupied Available'guest bedrooms does not exceed 6 Number of guests does not exceed 18 Breakfast is the only meal offered JWThe owner/operator is responsible for ensuring all consumers of this establishment are informed by statements contained in the published advertisements, mailed , brochures, and placards posted at the registration area that the food is;prepared in a kitchen that is NOT REGULATED/NOR RD/NOR INSE F.0 :u '- the FC-regulatory authority. Signature of Applicant: Dater Q:\Application Forms\Bed and Breakfast Exempt 2019.doc s f ASS SS r. SpgB COUUOMVULTH OF M�►CHUS� �cSl N0' oaj No 3!7 EXWUrNZ OMCL OF DSPAltTJMNT O? 1viROx AL AFFAIRS • O�1rTAL PltOTXCTION OFFICIAL INSPECTIpN FORM—N MZ s SUBSMACa SEWAGE DISP0 AL W Y 1 PART A TAM FORMCD AS HZ /Po,n 09MMCATION s �P�4► GGo Q,�, f �� T- Owoerh Names „ o a 6 3 v :n awaerh Admit p '' -mot Date or o 1�1ame arts p� Gr� I"'o<SP��' Compaq Names C Addrram o ox Tdephme ftnber: s w Oa 6�ts2 CERTMCAMON STATE I cwft that I hm Pewmd[j, the botow is tm%aoctnaoe and complaill as otthe t of Vskaat ftad* m aad that the hxlmI �3 and�gwjmm in the pepper mcdaa and The i "cd=wm �nrted aPp*'�ed permant b 3 Ion RV IND1�Ae pomlvocum I ss a Do cm MOM The&Bbmd 'Y�ne: _ Fab by the IOWg hwpe bes Slostorc Dates 0 The s!'acna inspector shall aubanit a mPy orthfa. ��E the sy� am���m is i sine or (Bound dHraith ar �'•T�origami should be seat to the owna shall t�0 t &°Bow a'I10,Mo awhoritjr, systaon owner ad copies sent to thebga. Me dthe 1l and 8 Notes ad Comment /l/0 �Gr401r► S p✓- fir v��� �I/2�/+ . •s.. report only deseiihp Mn \ tip Tbb dos not ad dWom at the am of inspecdoo and®der the condidoe>r of u dres how the systen,wig Pelforaa in dieCO°didona or use at that bture oader the same or diflereat Pale2aiii y OMCAL DIW ZMON FVIM_NOT FOR 3ETB5UggACZ SEWAGa DlgpO9AL VOLUNTARYASS %WM PAR?A gTRM 1NSPEcrlON FORM rhpatyAftm 3 ® rcATXON t 4,j 3 �- ll-�/��z a r.ti Cknw" all 6.?v Date at i�''C Gi!/l 0 Ir"°`doo Check AACA or s/AMU eam*%ar at Seetlot,D A. . __., 1 baMe not hood m7�noadot ahtCh 13.30c3 or hl 310�13.304 exist Atq*ne W o sod:d 20 ht 310 C C "tse Wratod below . AL Cao ,Psoeu _._ Om armor apraem as&Bcnw in thb,"Coodidend pne swd=need to be MPhod or aRNWW i9 the Based OtHeak win� Aaeaeryck ro arnot dftulmd(YjgAM in the ',be the wowing Cott 1t"etot mod•Pkase C&bks and ow ZD year old+or Cite scpdo�k ax ing tankiseopiaced w ar eat or tadr�!e Modoms(Mo mdat ar not)b segk twk as aPPWed byt6e win boa itfhe teetk ie MU tip 20 yew old it nw*k �sat leatigd a od its Ceram Qf ComoUwo ID cghin; ed adoa ats�gp badmp or beat out or hl wade�va4r aP )�an to x br'c cr4 sapled ar noevra kvd in SyslMwig bottat box due to kd..,w brohn PP(s)are etggaced won boa od ar ND expiaid rVlud 13e system PLO °°'t(th approval a<tbe BwW ot4Ht a�r dbe t0 bra of obsmLW P*s➢ no s3'se4e win PqW-._ob*ucdii is s➢M Mnaved ND explain; IPOP 3 of 11 DMC+IN PEC'I'ION FORM. •• ' gIIB3URFACa SEWAGa D NOT FOR VOLIII�I'i'ARY AULSUMM ' LPAftA Yg1'EM II1T3p r1�C1'ION FORM CUMWCAUON(cow lrerV Addnm Gr'i S OWN. C r✓I� Q DadeotL � G Fw//�tr ZVabWW 6 B�bs tie Bout a[unw. l MW whirl n+9u�ne&row evat lat pobiio7 the m�ewd=ui the Boarda[Horder dOarmd=�� L ��fur aalear Bali of� rt fi°dt°■[oi 6 s maItM u� p� oe witi pmk 314 Cal*ILMMM tot the _ ftdrimmew Ceaepoad ar�� SOlhet ars woe�r �'aftsad the P�+7 �30 Soots bofdmini y'rPated a'ulmod ar sddft salt mush - t theT% 1�a hOdl%�iai ad we*WPOM�ar s ro 4=tft=wave�,, and the sAs Ia a► 100 i�at at'a Tw Wkm Lar a septic tm*sd gS ed tW 0 a Zone I arc -- The Lae a septla bmt�US and toe a"����arc lie private SM sad the US it ku gm 1001 P�lvate �wen. wW*t MAWusedto d bnt SO�a<mmet�a • sysk,1 irthe� bactedn aodvoiw&orgudcwsWawa Permed at a DW d �e p�eamce alb °°mp°°acr t t6at the v is b+ee 9,rar a*bm W=Qit*l trt A ccP!of Ala*w to ar Isar jbw - and atbcbed b tidr} that no other 3: Other. P+p4od11 OMCLU'N'PECITON P0jW NOT SUWUUACE _ FO$VOL SEWAGE DISPOSAi,SYMIM;;g�A()NMSM, PSA A CATION(oaf Owner: C^ a A B �J �C�,� O✓ Dais of � M-p.2a SSystemFcaga I Yaam, i Cdkf a app to an� --• ,atawoa Yet Now 4. a system OOMIppct da to �' "' SASrar"�oeas to the a�os of the mud ae °r cbgg�gig cesspool — ligtdd Ind im the WRIMI be t d o am ova ar 1 ndon boot above �t do'M amIa oeuPol Is�to f below °waded or ctog 3A9 oe /fit tbaa 4 ttm� cL°g�d orV0bIM0 to b Man d'iiow �/-��4Paeion dtbe gA� d ar edp Si Nwbw �yPntfom dcesspool orp VY is�loo`�0'r btgd t oad sec NV*- cd da sttdba wa r -��Az VMdon eta assppci�! a �l or 6001yy to a smdba Podom ala cesspool ar is Zane 1 cta pd w�. sw*won Padm�no a 1 m PP y7 do ioo*a bot wa0arsuppb,y� p at a Dar !'%Atha°30$e2 a pris►aW� "die wail bee .fbr coiif�beet amid iftbe wen warderdhIM ad am cred.�ar�d equal16j��PAS provi or aaa�� be attached t9 t*f that se other hire ertberla i have tbe desartbed in 310 wed tw one or MM H&ft bo�mbte WX beQ^�me system Aft Th �dat at ry eo con"the owner sboald cbntect the Board at LWp a �si's'�the tips system Janet Yen� ciMa-ye'Or.*.to serve a tac,Uly wig a Beige eow d 10,000 ad to is" C°tmb ap*toLUP s3' tt ki adMom tothe c`�above) hem w witbm 400 fat ofa s �8 r �is witltia 200 fee of a a e tem is locaw In ota °ttr°S° arcs(Interim qr If � �—�A)�a mappod havea�� 9 �D above the lyee to any qaestfox in hasi3 the system is carmdarW a si I5.304 The system o"W dWd cotes t1pn UpSr*a the sstm ° CMWd ned a rq*W sae of ft Dpp UMd&0 O with 310 CDC L1 ,� • . Paasotil • oFFQCL4Li,�]Nspwno 14 NORM-NOT Fob vOU 'I'ARY �URBACZ UWAGR DIMKftL SYSTN� pA�8 ��L'!'ION FORM CMCNLNT Pkv"Addnm 3c�,o e '44 Dale d / O G6eet if the soQo�w�a . have brae doa�Yaat meat or-w n to each aim WU p'a+i&d bj ffie awnv .aocapM4 or BlowtadH� Wae av otdw "I�pompon 0M oat inthep�,ion two Weds pwlod FwG lww wlmnn alarm uy mooed ft do1°�b'n as pmaAthib waneasbum pkmatha alas andcmmbe WaitLe (raw w�emnw �- b wetted for sips as"W ba*up Was tbYe ails T iaspecaed ibr sips arbrea� waaaaUsystdn the SA4 Kiwi as site mkmmhdna[the >ma6er a �°°vr�°pn0�aadtbe .� watthe mat �hoishpp��� � lhoe cam(aad oo it maa )Provided arith sae 'ea''®° s9�ams m t6epropar The she ad bead ae at the SSW A 3 an the sips h Yes n�,.' as ban d wed or "—i/ as Fare�mp�sp,�a at tbeBaaeddE�� -- _ Dram h dia the&V(IrM,athe hbw clitab MbW b Pert C is at as )p10QMR IS.302P)(b)1 issue aPpmdmtbe a[dkam r , S , • �6d11 OM��ON FORS_NOT FOR VOLUl� UWAGR D ARY AM r AW C sT DFSMCITON FOAM o SySTAM WMRM UON owar. CiGr cC rq J a ✓c � Date atb 6 <i BtSipi�TLIL AAW conr m ��l�k�oZ Nlumber dbe�raaiot hosed o�310�g �ou�-G ., a Co �eddeadc oLl ` 110� k //oo f 4 low7am s Room hs�e s gArbaD �armk .vim �'� • r aenda �'�1Q w nok� Be...� mee smmmduxbesarmx 7ar °ccupmw COAMMRCLU nM��*.� v �of ��W Dedpfiow On Bask d BA ` 3!0 C�1�13.303x --ad aloafttmpi WN metepwm disci to the m 3 sy , k Last daps d &aod 6'a orno DAB(dex=ibe); of G �MATiOIr 4 °d M vntomeAact udtLe as11111111,lx �' — o w►+-w Ream* —HOW was y =R,'o'FSYST.. —shtecesopw absoapo� m l —Owzff ►cesgvd ._P*7 —Steed systeaa(yam orno)f� _Imoo y�atmch previous obtained j*6001M.Attach a copy d� ad 8tit mat Atmdt a cagy Of the DEP 4poW mmd°tenan°ecOnOW(to be Odler — ( er Appmjdm 30 orau dot ,, Wens O&MoToo G -e _ when arnviag *e(Yca or nor OFFICUL ' ION FORM-NOT FOB VOLIIl�i'rARY ASSE SUMMACE SLWAGZ D IjM,,oSAL,3YgT=, N ,CI .' oN SYSTEM�PART C �� RMATION(cootim o Prnperti Addreaa CI(7 /&Gt l , 45 fJ 0� 63� #I22 Al" ', Daft Or r� 0 , 13U=B(G SKM ooc t an*0 Fla* wowwak Mca fbb a _ oar east icon_� Cammeats(oo�ai�ia.aWdmll�oraocdm&a ( °x evidenat dlniraD,dmx SWM TAN$v pow an e Pam) M r&b 1 a Srxk Kmemt use a®x,_„ to aft aaa&med by a c woe . or no): aOWot Dhnwdmc/'?asDisimmh ftestapat,�dst toboitom a�cmlet tee orbiec .3s" of f'� Dlataoot Aoa�top 10 tv aadw too at mac 6 -// Lmstmm tiom folio®awam tobotGo�ml*1 fps ,a f add arbafH�//o — �� � ""� — �o T7`4 COMMON • C A c+ (mil Holt sae dfinetsima am mr (an�rt°°��°m°�°'a�iaiet� toe or bye ccn�tNaq dal how*.ligadd in*n d �,�✓ GRZASN on silt pion) a iir,%W ' � Y iooe woe�- — mt_ate �t6ici�: D1slaoot Amtop of tO WP arauttet tee or ba ft Date of�bottom��to boom ao�to or bed caumnaft(a°pPbd nhtbn nfta d as to°°ft�endence arEealc�q r as tea or 6a�e c iogray,b4Wd kvds OFFMCrAL JNSPWn0N FORM.NOT SUBSURFAC'Z SEWAGZ DUPOSA FOjt VOLUNTARY PART C UWWUON FORM SYSMM 0"RMAUoN(cow Owner. ed 6 SO Date et ,, WJGRT or moLDnqa TApMJL-'*=k=etbe Ihpth bebw gr� K1ocale m si0e piaoj t d�octioec- �Siooc Cap ckr D=IP Mow:Almom Gi.. ��b�arnok_ Y Oldscfhw Alm wad6XW aro"..), commom(candtdm�ad boat dad nisT�o�pH�G__._�� �t be opm aei site kfflft no/V17 4/ Comma*ftubwis�d atbaK etak ° �4�►3deooe atsa m, at Sm�C/ PUWCKUMM (bca0e an stbe pin) Armps m wark ng cedesAh=simw 6�ar noj: ( avft&aarnok commas a�pump .coodkine dpuMP and appalaoancM elk Pip 9dl1 - • OFFICIAL IlGPWnON Foam—NOT FOB VOL SU&q FACa S� WAGN BUPO AI,gyg ARY PART C P�;3PEC'IION FOltlll ��Il�TF01tMATION(oo�oue� Owner= �l u*C4C'l"S �} O�G20 �Gr v! Dah d L o S40XABSORMON SySTiet OAS): goeaft an�e Pam,ezesvallora aot r,equirea W SAS mt locaw cq" k Piemum -- aoniber; X PSG - �a s f w e�H o kl c. - amoval�lvefalcaUP04 nmmber.— j ox°�Iti(°°d° s�Bosa[hy °� e d g,� �P34 ON , f d, ti o-el - o� �$1 c � l° ro� Cza1''OOL4:�(�s�od�be pumped as part die as s� li Number aad ooao8 l� DeA atsoft byw � Dieo deem d COmmcnis coxom a� (Ya ar mX W4 Sias°fby �41evd dpoa�g�toa dve �.r PRIVY:,�pnraoe as Sib plan] emm'Depth dsa�der s mote oond m of SA Ugm CfY&Mkham%lavd at paw aond6ioa atvegetatiaq��. . 9 -pow lO dll OFFICIAL IlNSPZ MON FOAM—NOT FOR VOI.MART ASS�S311�1�ITS SUBWMACZ SEWAGZ DL4POM SYSIZM INSPZcmoN FOAM PART C ' SYSTEM ROOAMATION(oomminue�, Ys+operq Ad�+e� J b 0 DAftdbqmcdmOy SMCWKZOFSCWAriSMTZK boat tam ee�m�m.loo�laeale.�epabBcr�ar�,�.tbee� Co�{c9� /¢7- qtJ " d - 33 i 341 •• - -Ps8P11d11 . • OFFICYAi.IN3pEGTION FORM—NOT FOR VOLUNTARY A33B.3311IEriT3 SUBSURFACE SWAGE DISPOSAL SYSTEM IlpISPECTION FORM PART C SYSTEM DMRMATION(aoadmed) - o•••m z4f ZQ(-f isle d gn KUMOaftw • z Cbecicamt pftm w m*vow —�ldued�+as myslam daed®a pim asreond-Itcltecbe�dale ddeaS(A�t�pme�evkwed;i wl�local Baa�ddHm � t�`Gi �l _C3edbedwhlloni mocsvalma�iosbalkrt(attacl docomaotadou) Accemd U=d —him You aid&smla 3 bow you eslsbltsbed ht� ws�ar devado� e z Page 11 of l l B OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - i SYSTEM INFORMATION(continued) Property Address: Ashley Manor 3660 Main Street,Barnstable,MA-02630 Owner: Dormid-Bain Date of inspection: February 16,200.1 SITE EXAM ✓ - Slope Surface water. Check cellar Shallow wells Estimated depth to ground water o2' feet Adjusted high ground water elevation .23 feet Please.indicate(check).all methods used.to determine the high ground Hater elevation: Obtained from system design plans on record.-If checked,date of design plan reviewed: 47 Observed site(abutting property/observation hole within•150 feet of SAS)(9/0 s Checked with local Board of Health-explain: Checked with local excavators, installers-(at4aeh d6eumentatie Accessed USGS database-explain: You must describe how you established the high ground water elevation: t—o t a w -A .../r+ r...w�_3 t...aJ ...s.i A W .;a,. wn. I tn..�v- t_ //rtL�:-.(�.t • QV•4r¢.l. BC IrY+M ii�/ /LK � /'I ,NG i /iD, /f ✓l Q�'_ 0.J t /M 62" L h L>0, W u( / IJV H 4-o 4.. A /C.... .Y. S W(I`c. u 6 tL.L,i/� •T1•V h ArNL. U I LY I C+ / 104Z./ 1PLJ. G`T1 PU VJ✓1 C...w�O L Ch . t Y.1. 11 Town of Barnstable Department of Health,Safety, and Environmental Services 'BAR Public Health Division P.O.Box 534,Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Apiil 17, 1998 TO: Arthur Traczyk Principal Planner FROM: Thomas McKean,RS, CH Director of Public Health RE: Ashley Manor/Response to Your Letter dated April 14, 1998 r I am in receipt of your letter dated April 14, 1998 regarding the Ashley Manor application. MAIN HOUSE The main house does have an adequate septic system for eight(8)bedrooms plus the two (2) additional bedrooms proposed. It consists of a 2,500 gallon septic tank, distribution box, and two 6' X 6' leaching pits, stacked one on top of the other,with five (5)feet of stone surrounding them. According to Mr. Ojala of Downcape Engineering Company, the existing septic system is adequate for ten bedrooms under the 1978 Code. Thus, it is in compliance with the current Title V regulations for the proposed two bedroom addition. Also,this septic system for the main house was inspected by a DEP certified inspector, Troy Williams, on February 19, 1998. He completed a ten page report, certifying in writing that the system had "passed." COTTAGE Unfortunately the septic system inspector, Troy Williams,was unable to locate the septic system for the cottage on this property. His report states: "due to the age of the cottage, system would most likely consist of a cesspool. Effort was put into locating the cesspool, but was unable to be located. To locate the cesspool would require an electronic mouse locating system and possible excavation with a backhoe which may disrupt the driveway and would be costly to the homeowner." Thus, we have insufficient information regarding the septic system connected to the cottage. Therefore, the Public Health Division will not approve any additions or'any other building permit applications associated with the cottage,until after such time the information is received as required by Title V,the State Environmental Code. Please feel free to call me if you should have any questions. l , TOWN OF BARNSTABLE BUILDING DEPT. Town of Barnstable D DEC 3 1 Application for Site Plan Revie Location Business Name: 45,E be ano/1 Assessors Map and Parcel umber: W A,2 LLLet7 - Property Address:` 366o R F • 6Ar 13a��s ta5ip /� Owner of Property ' Applicant 09497 Name: '),rs"a►u! '(ja ^ Name: — j Address: 5460 rn a !'f /t 190r Vnx YY6 Address: Ili/n 51cr 01r-36 Phone: <�o C�e,f e� 1 • �.Qtn+a Phone: c l e ('e k� . Fee.-,a., 36 y o 0 '36a y'7ao FAX: 36 �- ea3l Enxdnee Agent Name Name V t+?. L. Address: Address: -318o rya I F t' o- Sox 198 Phone: Phone: -3 6 a - y?o o Storage Tanks Utilities Zoning Classification Existing; Proposed Sewer District: {Z - Number: 'Number: Public Flood Hazanl: C Size: Size: Private Groundwater Overlay: Above Ground: Above Ground: Fire District Lot Area: r1.2 1 .2 gs SF ¢ Underground: Underground: Water Number of Buildings Contents: Contents: Public: 1/ Existing: Private: Proposed:-3 Parking Spaces Curb Cuts Fire Protection: Demolition: o Required: I p Existing: 6 h e Electrical Total Floor Area Provided: - ti;�, 6t Proposed: one Aerial: Residential: 599� S. �+ On-Site g - , t To Close: 6 Underground: ✓' Office: p Off-Site: Totals: 0,1e Gas Medical Office: o Natural: Commercial: O Propane: (Specify Use) o Wholesale: o In Area of Critical Environmental Concern Institutional: p (E.O.E.A) Yes Industrial: n Project within 100' of Wedand Resource Area: Yes N& 4 r, Old King's Highway Regional Historic District: c� APprovedP �qNo Zoning.Board of Appeals acdonP-jqA I,cA-1�—, Tor lro►^:a�cC 4�� Listed in National and/or State Register of Historic Places: Perimeter setbacks: , Front: rl S Side: y a I o 8 -- •Rear: � 96Lot Coverage' 2nll': `I g co Ko Number of Floors: a �2 Floor Area: y 9 S R P x ;.+ ' 9 r n 1 8 b Se- �♦ . e co„d 3hrti aal r, t D-- First: 2si 'a Other (Specify). 2 x 2s s a -, 54"1 A���t,o., S� Parking Requirements: /• a x t a Required: o Provided' 6Ldd� Handicapped Spaces: Are there Accessory BuildingsP .�,ed �►e�f4+� Accessory Building Floor Area: Ca h«,s c Soo s F Please provide a brief narrative description of your proposed project. O O � (/Art"G1 Q aid �� .r Qc.'a� / 'e/•+,� f L� _ add 2 se +5�(rem '-JA �t Vic )F:4 of rent I assert that I Lave completed(or caused to be completed)this page and the Site Plan ReviesvApplicatron and tha4 to the best ofmyknowledgc, the inlonnadon submitted here 3 is true. Signature a�rer Date 5 7 " E f 474t7 E �a 6 / D 7 NI a � til- o a0 . L6• . • � /q 8 Q s s. 3 10 Q � r it ---- 60. 2 — �'3G(ep /O2•G �� n STORY Spq�e� / 12 ! 1 X Zoo 67 /V S4 3 8 • �o„ � �. `S 777,4 TE 2 3�. a 4 .•' ti/G ywa y RouT-C A TOWN OF BARNSTABLE ZONING BY-LAWS DATED FEBRUARY ,1986 oi PAUL � ZONE. RF-2 n. �` SETBACKS . nYLL N FRONT 30' No. 32aa8 A �.►-��! SIDE iS' ►►may` i►Nof�, REAR 15° Ashley eXanor � - 4 VU 40 3 0 �x, 3u�i i, 1. f# ,KnA,•4Y� ; 1;�"t al`o1'�M� eVM�N�KM...�.,: _ .I d74V►.J/j 'I�,1'•, `' Ago- a small country inn To experience Ashley Manor is to discover a very special place! A,prestige inn located in the heart of Just step through the front door of Cape.;Cod's:historic;district,.Ashley.' A few of our very special places and things... Ashley Manor and you'll feel imme- ' diatel at home in its elegant yet intimate itin t '- Y Mano?i disctive stirroundm p greet l '�""" a you warmly withtth6elegance and ro ; j j�f't�i� ; �;� I interior. The parlor and keeping room . ' ,, invite• ou to relax b a crackling fire jmance of the past;With roots that go;l , jty, Y Y ale s rr .�, , backutoucolotualCdays, AshleyYManor�6� 31 :;where you'll experience a sense of s e'MO-t etl of;thelt3tgmtyiof an all i` r'=` #I; _ �I° timeless tranquility surrounded by Abuf=for Otte wa of life If£you are , L' �I antiques, oriental rugs and handsome g,axy ,.,Y :tt eta q an org' ltosel in yearnto�escapello =r i'f� ,° country.furniture. Both rooms are large 7 i t"tlie gia _otis„„•55tyle of Uhegpas;Ashley; 1; .!� and.sunny and open onto a beautiful 1Vano` isheSSSgee sanctuary� =�'� brick terrace overlooking the inn's -t } 'flit i 3, 4 exquisite; park like grounds. The $,Hiidd sbehind �hugel pnvet'. tedges;, u�xa � a� ,w�,: innkeeper's famous complimentary Ashley Mane ftrst Invites ou m u a Our huge hearth with its beehive oven invites you into. P ty , p ' {` lour;livingroom`to relax, by,the fire, to share gourmet breakfast is served either here, longsweepmgdnve�way; Here,�i�thed , t conversation to enjoy an aperiuf on the terrace or before a roaring fire in shadetand beauty ofl the inrV, ilovely I k �Kf Iur 3 t. _, { , K sa o#acre estate dare quickly-.revealed.4 the formal, candlelit dining room that at '�` � boasts charming corner cupboards 'Sa�elyhold trees a ound:Graceful s�we r t' wii ?t v'ty=1 .i r r I; � cl wood){ed es,wind therr wa 'throu h ��' y ' =- R displaying a fine collection of crystal, o)iip'frr• N;�g , t c,x y.: g. ' r,•�':. i I ,;' out�aiarucured lawns A classic foun china and the pottery of local tai- ardenttouches;the•spirit"with its - . ., .:._.. � .� ,., . _ ' � -- --craftspeople_ -siinplcharmony-A^chartning-gazebo-- The nostalgic aura is echoed throughout completes.the aura.of travelling back �. � x- the manor house, where you'll enjoy throu time; while a;carefully sited - your stay in any one of the inn's six tennis hcourt.blends so gently into the. — " - romantic guest rooms or suites.Each is a surrounditt s it seems as if it has al-:: Enjoy,another livingroom view our park-like grounds s acjo WayS`beeIl��liere beyond the delightful brick terrace where summertime us, beautifully appointed private p hi breakfasts are served refuge.All feature modern private baths Ongrnally,built,in 1699,Ashley,Manor;; I ; s and all but one enjoy working fireplaces. has,seen' `many:;'additions over the .xr Each room has its own special charm, centuries W,xEvidence of..,its age and ( �! s '. 'i� i' highlighted by distinctive wallpapers. _ y ;. a., history can be seen in the wide board:d�' _ =li .� , ' Some feature New England shuttered :flooring;400d`usually,reserved forte. j {,I ,T; j• , windows,'colorfil old sparkled floors or =ea�tduring colonial times;huge open glamorous canopy beds. All include W,,-fireplaces,' one with a bee- ' ` /�"'�" rT-""}, I as those lovely small touches that reveal the hive oven; hand-glazed wainscotting - _ & .; innkeeper's caring attention to even the a � . . just;about everywhere and a secret j - _ passage'connecting the,upstairs and smallest detail: fresh flowers, imported downstairs suites—thought to.be a bedside chocolates; the finest soaps, hiding place for Tories .during the One of our most elegant suites,highlighted by a queen shampoos and lotions, and your very Revolutionary War. size canopy bed and,of course,a working fireplace. own coffee and .tea service for your indulgence any time of the night or day. A6 TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (506) 385-1500 19 Hummel Drive South Den?*!�-\MA 02660 . COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPAR COPY DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02109 617-292-5500 WILLIAM F.VELD Govcrnor TRUDY CORE Secretan- ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr PART A fis//6ey AllaMoR CERTIFICATION Property Address: 3(O&O f 9 /9 8 Address of Owner: Date of Inspection: (If different) Name of Inspector: Troy Williams 2 I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 1S.000) Company Name: _Troy Wi 11 idols Septic Inspections Mailing Address: 19 Hummel Drive- South DPnniS MA 02660' Telephone Number:. (F n R) R —,�-,-3 5-13 0 D 6.2 c �d CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses M 4..ti I bus; c>H �� Conditionally Passes 5 — Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: JA:. 3/ !•t/� Date: 021 9 /9c9' The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION.SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: �I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 1S.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: /V119 One or more system components as described in the'Conditional Pass' section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If'not determined',explain'why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. - (—i—d 04/75/97) Paga 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3660 Main Street,Barnstable,MA Owner: Donald Bain Date of InspectionfebtUary 19, 1998 Bl SYSTEM CONDITIONALLY PASSES (continued) A/�,q Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box., The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are.replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N119 Conditions exist which require further evaluation by the Board of Health in order-to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF'HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND'THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a'surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3660 Main Street,Barnstable,MA Owner: Donald Bain Date of Inspection: February 19, 1998 D) SYSTEM FAILS: A///j You must indicate ei;,.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. _ Any portion of the Soil Absorption System, cesspool or privy::is-below the high groundwater elevation. Any portion of a cesspool or privy is.v?ithin 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: qX9 You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above:'"r The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area - IWPA) or a mapped Zone ll of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program, requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Pape 3 of 10 .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 3660 Main Street,Barnstable,MA Property Address:Owner: Donald Bain Date of Inspection:Inspection: Check if the following have been done: You must indicate either."Yes" or"No" as to each of the following: r Yes No , Pumping information was provided by the,owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates. during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. ✓ _ All system components,-excluding the Soil Absorption System, .have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner(and occupants, if.different from owner) were provided.with information on the proper maintenance of / Sub-Surface Disposal System.' �L Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is . unacceptable) (15.302(3)(b)) (revised 04/2S/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3660 Main Street,Barnstable,MA Owner: Donald Bain Date of Inspection: February 19, 1998 RESIDENTIAL: FLOW CONDITIONS Design flow: R$o g.p.d./bedroom for S.A.S. Number of bedrooms:__$_ Number of current residents: Garbage grinder (yes or no): /%/o Laundry connected to system (yes or no): IFS Seasonal use (yes or no): /Nb Water meter readings, if available (last two (2) year usage (gpd): 97 a s `r/,,, Sump Pump(yes or no): No S 6 - Last date of occupancy: COMMERCIAUINDUSTRIAL• Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_. Non-sanitary waste discharged to the Title S system: (yes or no) Water meter readings, if.available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: � �w : c. ��'. 14 to�t h c� lit a ....� v .,J�c ✓' Systerfi pumped as pan of inspection: (yes or no) o If yes,volume pumped: gallons Reason for pumping: TYPE pF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other . APPROXIMATE AGE of all components, date installed (if known) and source of information: �s +a It 4 .� Sewage odors detected when arriving at the site: (yes or no)ill c (revised 04/25/97) „ Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3660 Main Street,Barnstable,MA Owner: Date of Inspection: Donald Bain February 19, 1998 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: Zconcrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 6 S x I o2 x 7_' o2s0 6 Sludge depth: " Distance from top of sludge to bottom of outlet tee or baffle: �� Scum thickness: No/VC Distance from top of scum to top of outlet tee or baffle: /Yam ww. Distance from bottom of scum to bottom of outlet tee or baffle: Nd S c. ter•, How dimensions were determined: Comments: (recommendation for pumping, condition inlet and outlet tees r baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) I Z_eS L,J c r-1 - �,, J }a t , ,, w ; N 4 J�CA G&—, /I/. GREASE TRAP: IV14j (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) f (rwiud 04/15/97) a Page 6 of 10 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3660 Main Street,Barnstable,MA Owner: Donald Bain Date of Inspection1.ebrtiary 19, 1998 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: —L/ (locate on site plan) Depth of liquid level above outlet invert: LJ,c I Comments: t (note if level and distributio is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)_ 0-6ax . PUMP CHAMBER (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) 4. Comments: ° (note condition of pump chamber, condition of pumps and appurtenances, etc.) - (ravisad 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 3660 Main Street,Barnstable,MA Date of InspectionDonald Bain February 19, 1998 SOIL ABSORPTION SYSTEM (SAS): . (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: ` Type: i leaching pits, number:,? - F' �� (,c..cA �-� �,f-s (S�c,_�(.c�J, � W,•{� � S l leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraa� u ulic failure, level of ponding, condition of vegetation, etc.) If o CESSPOOLS: A114 Se- )IC-"4-S. (locate on site plan) 5 t 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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: N0. (locate on site plan) Materials of construction: Dimensions: ` Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,PART C SYSTEM INFORMATION (continued) Property Address: Owner: 3660 Main Street,Barnstable,MA Date of Inspection: Donald Bain February 19, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Na k • S�tif�, �a„G 5// ' a566 S3� - yy ya 'L ° _gax 70 a - L 'xd S Ck-, n (ravlaad 04/25/97) Page 9 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3660 Main Street,Barnstable,MA Owner: Donald Bain Date of Inspection:February 19, 1999 Depth to Groundwater-32 Feet ,23 adjusted high groundwater lend Please indicate all the methods used to determine High Groundwater Elevation: T Obtained from Design Plans on record Observation of Site(Abutting property, observation hole, basement sump etc.) ,Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local a G&vaieri, is. t6 ers Gh 9,ti VLr s Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) LU c.,o. � q ro.��,Jt wu��c c� C��,► �..�u r N..c�.�o S �S � o c../ �ro J ti�w�.-�-s 3.2 A .3 a �-, �. . I ( '/ t, C J Y S C-o ti4Vf A.-../� v/ ti y S W c O % 741 el- A✓ hG � Jc=1A /pie P_L .5. 0. t (Do Caves £h, •h c-.� i�j , t Y�.,o� po��- (revised 04/2S/97) a Page 10 of 10 JL T`' -�j G G 7` C c� S ` / S J T t '+1 (.-� o ./l ✓vr i� S k.tily C. • hs � /t c) 7e -' /I � cjc— 7`/a o Jo c4e�.f N'�U .l` ✓ S /�- l W �, C, t .. 9 �\ COMMONV►rEALTH OF MASSACHUSETTS ,1 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE %l'INTER STREET. BOSTON, NIA 02108 617-292-5500 R7LLIANI F.WELD TRUDY CORE Governor Secretan ARGEO PAUL CELLUCCI DAVID B.STRUHS D.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION '/�SHUt-( MAf�tUR-r Property Address: 3rGo Address of Owner: DONPl.O WN Date of Inspection: 4`2 2.19 8 (If different) Name of Inspector: A(z),t-i_ o.jAt,,� I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Vow,,, C�.o,o q syt-eenkI Mailing Address: C" Telephone Number: IA 9 WI0U-M+90dLT t Mk . 0 Z G G CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: \\ Passes ro c O NG y� g 1A4jUe/M 2_� AZ' �h( (ti�Y u3t,u t�'�J r9a in> /� JJJ _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails C cam" Inspector's Signature:--,V0L--""` '--�-� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving :authority. INSPECTION SUMMARY: Chec A, B, C, or D: AI 'SYSTEM PASSES: v I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES:One or or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, o ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attachvd) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic: tank as approved by the Board of Health. (revised 04/25/97) Pace 1 of 10 OEP on the Wor':d V:de Web: ht';Jtwww.magnet state rna.us!de;, `3 Pnn;ed on Rec--led Pape- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM LL' PART A CERTIFICATION (continued) Property Address: 33t'ao M4-(/..1 S! Owner: Vo t-) 'L 9 (F5 (N Date of Inspection: A(Z9- B) SYSTEM CONDITIONALLY PASSES (continued) /V h Sewage bac u r reakout or high static water level observed " e distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution b . The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is le v ed or replaced The system required pumping re than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval the Board of Health): brok pipe(s) are replaced o truction is removed -------'--- C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation b,t ea in order to determine if the system is failing to protect the public health, safety and the envir 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMI S THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT: _, Cesspool or privy is within 50 feet of a surfa water Cesspool or privy is within 50 feet of a bo ering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF EALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MA 'ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic t and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface w er supply. The system has a se c tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a s ptic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water s pply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is fre m pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5'6—pm. Method use me _istance pproximation not.valid). 3) OTHER (revised 04/25/97) Page 2 of 10 1 --..s / SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / PART A CERTIFICATION (continued) Property Address: GO MA r-J `i 7— Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate ei;•,er "Yes':or"No"as to each of the followi I have determined that the system violates one or re of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The and of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility r system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of uent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level i the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid dept n cesspool is less than 6" below invert or available volume is less than 112 day flow. Requir d pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Nu er of times pumped_ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any ortion or-privy within 100 feet f a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within,50 feet of a private water supply well. _ _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes"or "No"as to each of the follow,' g: The following criteria apply to large systems in ad ion to the criteria above: The system serves.a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and'safetyIand the'envifonme because one or more of the following conditions exist: Yes No T the system is within 400 f t of a surface drinking water supply the system is within 0 feet of a tributary to a surface drinking water supply the system is to ted in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public water upply well) The owner or operator of an4 uch:sy;s;eshaII brink(he system and facility into full compliance with the groundwater treatment programrequirements of 314 CMR 5.00 and Please consult the local regional office bf the Department for further information. +J v (revised 04/25/97) Pago 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 5 0 */2 n. Owner: A5,4Qf y �d / Date of Inspection: QpAJ,'LO /�1A �lzxl�g­ Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following: Yes No ZPumping information was provided by the owner, occupant, or Board of Health. _✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. ✓ The site was inspected for signs of breakout. ✓ _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C � ® SYSTEM INFORMATION Property Address: Daleo D ?7 Date of Inspection: Z� Q '//Z/g� FLOW CONDITIONS RESIDENTIAL: Design flow:, L�.p.d./bedroom for S.A.S. Number of bedrooms:_ Number of current residents: Garbage grinder (yes or no):,A/a Laundry connected to system (yes or no):�✓� 9`_�y�o,� o t Seasonal use (yes or no): Al Water meter readings, if available (last two (2) year usage (gpd): q7 7$6go"c) 5 oT'$-� �m Sump Pump (yes or no): l�/0 14&7 Ga Last date of occupancy: COMMERCIALIINDUSTRIAL• � — Type of establishment: Design flow: gallons/day Grease trap present: (yes or no Industrial Waste Holding Tank pr ent: (yes or no)_ Non-sanitary waste discharge o the Ti ystem: (yes or no)_ Water meter readings, if a Last date of occupancy: OTHER: (Describe) Last date of occupant),: GENERAL INFORMATION PUMPING RECORDS and sour a of information" fL System pumped as part of mspe ion: (yes or no) If yes, volume pumped: gallons Reason for pumping: hjgj M mutt—f TYPE OF SYSTEM Y Septic tank/distribution box/sed absorption system Single cesspool Overflow tesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE ACE Qf all comRgnents, date installed (it known)and source of information: - ?fir yP B 62,ni?) Sewage odors detected when arriving a)the.site': (yes or no) (revised 04/25/57) page 5 of 10 r- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3d,60 Owner: ��/_ �flvrf CJ —�OvI a /• ,��v�-J Date f In pection: /P 2� BUILDING SEWER: (Locate on site plan) t Depth below grade: �- Material of construction: _cast iron )C 40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_v (locate on site plan) d Depth below grade: w Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) //1' Dimensions: � [/X X /� /CY7t� 4— � Sludge depth: !/0 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: / ii Distance from top of scum to top of outlet tee or baffle:. „ Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: mtien..� w� Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relatio to outlet invert, structural integrity, evidence of leakage etc.) ,rL c,Q a d GREASE TRAP: (locate on site pl n) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explainj Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) + Property Address: v Owner: Date of Inspection: �ZZ/jrts TIGHT OR HOLDING TANK:IN( ' (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass olyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day - .. _�•;. _. Alarm level: Alarm in worki order_Yes;_ No Date of previous pumping: Comments: (condition of inlet tee, condition alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outl Comments: (note if level and distribution is equal, evidence of solids carry er, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes No) Alarms in working order lY or No) r ' Comments: (note condition of pu chamber, condition of pumps and"appurtenances, etc.) (revised 04/25/97) page 7 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: (o/ol�V Sr Owner: �� Date of Inspection: �rzz;1#1117 SOIL ABSORPTION SYSTEM (SAS). (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. to Ae Gc>/f�t a /Sfax e�r leaching pits, number: leaching chambers, number:_ leaching galleries, number: �— leaching trenches, number,length: �— leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, con ition of vegetation, etc.) ,ram v N co w a b t.A.,c -� v.� a CESSPOOLS: (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: JJJ inflow (cesspool must be p ped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level`of pon g, condition of vegetation, etc.) PRIVY.- (locate-on site plan) Materials of construction. !Dimensions: D**.of solids: Comments: ' (note cpndition of soil, signs of hydraulic iture,'leve1'of ponding, condition of vegetation, etc.) ._�.. ' Ar (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3(p r, N 5-r-, C,O nAl&.�J Owner: PU IV/A L Q (bA Mj Date of Inspection: Depth to Groundwater 3Z Feet Cce-A' _kJ 3 4�GIC�y Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data cG� co�Q c rt�t�fsron ntaP� 04rzs�i¢13Zh Describe in your own words how you established the High Groundwater Elevation. Must be completed) GI C-C*�c b 5 ta^- Imct(J e'4C�L" wM-4k r (zevimed 04/25/97) Page 10 of 10' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: jG�p Owner:Date of Inspection: 00/ N4t a 1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) J A`Lu QNf R co rt A(y� to- 3 Icx�o �. S.T. �^�45u2E.►►'�5.��✓ . p 3A.5 13.6 (Yevieed 04/15/97) Page 9 of 10