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HomeMy WebLinkAbout3688 MAIN ST./RTE 6A(BARN.) - Health 3688 ` ai S-tieet Y� ainstab e - A= 317 024 c Commonwealth of Massachusetts Title 5 Official Inspection Form f 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /` 3688 Main Street 4 Property Address Tony Saleh Owner Owner's Name �,r information is required for every Barnstable Ma 02630 11-12-2020 t: page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name keys 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code m01 (508)477-0653 - S113747 - --- ° 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 Brett Hickey ;Digitally signed by Brett Hickey ll k Date:2020.11.1610:14:47-05•0o• 11-12-2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a'design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 n i Commonwealth of Massachusetts Title 5 Official Inspection Form --� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yJ 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every 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 was in working order at the time of inspection. The tanks inlet and outlet pipes are both pitched backwards but the system is still functioning properly at this time. The dwelling also has a garbage grinder and system in not designed for it. It is recommended that the grinder be removed to prolong life of SAS. 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): l5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every St page. City/Town ate Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: El 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh , b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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 ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.'7/262018 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less than Y day flow ❑ O Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of-times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ E The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 w ssachusetts Commonwealth of Ma �= Title 5 Official Inspection Form p} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ❑ Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? ❑ E 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is required for every Barnstable Ma 02630 11-12-2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440/GPD Description: Number of current residents: 3 Does residence have a garbage grinder? Q 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 Ej No Seasonaluse? ❑ Yes CE No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2019- 90,000gallons 2018- 62,000gallons Sump pump? ❑ Yes No Last date of occupancy: currentDate h 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >.� 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: V 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: , Owner- last pumped in 2018 z Source of information: Was system pumped as part of the inspection? ❑ Yes N No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 OfficiaU Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owners Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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: 2005 per plans ' Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: " ❑cast iron ■❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 ii C� Commonwealth of Massachusetts �d Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System `Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ❑® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) r If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 500gallons 8rr Sludge depth: 26" Distance from top of sludge to bottom of outlet tee or baffle 2r� Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 14" Distance from bottom of scum to bottom of outlet tee or baffle measured 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.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: — gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) r 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): Orr Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. r t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * 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: i Type: ❑ leaching pits number: (3)500 gallon chambers leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every 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.): The SAS was in working order at the time of inspection. Chambers were dry with no evidence of past backup. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 l � . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): } i r f t5insp.doc-rev.7/26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 ' c Commonwealth of Massachusetts �^ Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owners Name information is Barnstable Ma 02630 11-12-2020 required for every 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 wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately TOWN OR BARNSTABLE w �- LOCATION_i'3GgS MQi/1 Stif SEWAGE# 9OOS. C? VILL-AGE a► rn%Aa ial c 1' a ASSESSOR'S.MAP&.LOT INSTAI..LER'9 NAME&PHONE'NO. Q o l r-1 G,*)9SL g 1�17—p G c 3 SEPTIC TANK CAPACay'4! T' LEACf3VG FACILITY: (type) TOO daLf j:11 icrS (size) /3!x 33..5' NO.OF BEDROOMS C/ BLM.DER OR OWNER PERMTTDATE: DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and.Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and.Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A - 38 Ccinen'I AZ = yy c y G CS —$3' .B6 = co ` CG3y.l � s .. � t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 x ` i I n coy Commonwealth of Massachusetts Title 5 Official Inspection Form 'yP Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑� Check Slope ❑■ Surface water ❑■ Check cellar ❑■ Shallow wells " feet GW@180 Estimated depth to high ground water: - Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed: 3-25-2005Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: s You must describe how you established the high,ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Offdal Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3688 Main Street Property Address Tony Saleh Owner Owner's Name information is Barnstable Ma 02630 11-12-2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: �■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed&Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t t5insp.doc+rev.7@62018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 119 of 18 r _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I> �^M 3688 Main Street Property Address Colin Campbell _ v Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. Cityrrown State Zip Code Date of Inspection N , 4w.. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information q D ' on the computer, S I ,* use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy, use the return Name of Inspector key. B&B Excavation r� Company Name 374 Route 130 Company Address few Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-25-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ilk i Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s).or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in.accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments �M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. r ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet o'r more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 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 ❑ ® 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 3688 Main Street Property Address P Y Colin Campbell II Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. City/Town State Zip Code Date.of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion.of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3688 Main Street M Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma. 02638 3-25-16 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ® ❑ Y P ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: _ Number of bedrooms (design): ,. 4 -Number of bedrooms(Actual) 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 459 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is Barnstable Ma 02638 3-25-16 required for every - page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents. 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail 2014-271,000gallons (742GPD) 2015- 181,000gallons(495GPD) Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. City/Town _ State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: ' Source of information: Pumper Driver Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: - 1500 gallons How was quantity pumped determined? Tank size Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and,a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is Barnstable Ma 02638' 3-25-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if.known) and source of information: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: 1500 H-20 Sludge depth: 8 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 6 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 12 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank was pumped after inspection and should be pumped every two years for maintenance to prolong life of SAS. Grease Trap(locate on site plan): Depth below grade: NA p g .feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): I Dimensions: - Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is Barnstable Ma 02638 3-25-16 required for every ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 in working order at time of inspection. D-box did not show signs of back up but heavy carry over was present. 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.): NA R * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 R_ r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is Barnstable Ma 02638 3-25-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (3) 500 gallon ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to.inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ' 1 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately DWELLING All.* B11-S A2-" 82-2 - 83-6Tn, CpM� 8q1 A S548l" 6401 C6-6.1 FLAG LE DRIVEWAY' CEMENT BOUND t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 3688 Main Street Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GW @ 180" feeee t 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: 2-22-05 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file with BOH. r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 M1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 3688 Main Street �M Property Address Colin Campbell Owner Owner's Name information is required for every Barnstable Ma 02638 3-25-16 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary ID (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION sir 49 ,4 SEWAGE # VILLAGE gq,@,��-,g(�(� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. f SEPTIC TANK CAPACITY /vno Ca9L QLrrc/e 1geeL vaerg/T Ta..1g LEACHING FACILITY:(type) 1%tccK (size) Sao 4-74L NO. OF BEDROOMS 44 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERC1�r DATE PERMIT ISSUED DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No pRo,4bsw/ r Q e ooi A 6RAss_ . A�e�A w- TOWN OF BARNSTABLE � LOC'AT[ON .V.R5? lea►n Sf . SEWAGE # 900S - 10 ,LAVE \B7 rrnS40—L'1 c. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. R oSmri G iK"ou Y??-O G S 3 S PTIC TANK CAPACITY _/.SO O 9 n-J e?0 LEACHING FACILITY: (type) S00 ya.l ckmo,Scr.S (size) 13 �x 33.S x a r NO. OF BEDROOMS q BUILDER OR OWNER ClowS PERMIT DATE: '3-PS -OS" COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge,of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Al = 3s ` AZ 49 ' B3 GSA C 3 =S8 ' -7& ,B S CS • S'3 ' BG = en ' 'CG No. S I s-'' f f Fee — n '" Y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pphratiou for Miquar *pgtem Congtrurtton i3ermit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components t e v Location Address or Lot No. 36$I?A�%q 1 fl S t Owner's Name,Address and Tel.No. ' CI c1e C Assessor's Map/Parcel �4 rn5irAb Le M-A y IQ U55 8' — 4 6 a 3)7 L 2 ox Id85 Installer's Nawe,Address,and Tel N . Designer's Name,Address and Tel.No. Qxcava-h6 3bbVi 6 11� Dafren AA . Meyer es � albeeal Ln -f-0(e5tdole �Abz 614 Sox 98+ 15. 54nda)(4h d2537 Type of Building: Dwelling No.of Bedrooms Z— Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow_ gallons per day. Calculated daily flow -gallons. Plan Date aa o 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) 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date . a Application Disapproved for the following reasons Permit No. 29oS — 10 Date Issued 3 3 0 IC / Fee 06No. - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLId HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes 2plication for 0iopont *pztem Cottgtruction Permit > Application for P rmit to Construct( . )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components \Location Address or Lot No. 3 6 M G n S Owner's Name,Address and Tel.No. MA CJyc1c CIgUS J2y� Assessor's Map/Parcel I G�t l Stu b l�: b X 1 C, 317 r _11dif, tAA 50u- - a 6S t ,Installer's Name,Address,and Tel.No: Designer's Name,Address and Tel.No. �3t(�.Excc�vclt�on- Ul��( I h I FGy �e<«ens M Meyer lz.s , I`i TeGbP,erzy f U`P51(101P LjA OZ694 3©x 9 � �� �. 5ciI-Ida)(&h p2637 Type of Building: Dwelling No.of Bedrooms_�- _ Lot Size sq.ft. Garbage Grinder( ) Other-;` Type of Building No.of Persons Showers( ) Cafeteria( ) p Other Fixtures Design Flow /_4 t_I n gallons per day. Calculated daily flow -gallons. Plan Date 2 -A ,11f_e,Number of sheets Revision Date Title Size of Septic Tank S h() Type of S.A.S. .5 0 4) f,(,1 . 't h Gi n )h PJ( _S Description of Soil O Nature of Repairs or Alterations(Answer when applicable); t Date last inspected: Agreement: Y 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 Certifi- cate of Compliance has been issued by this Board of Health. t Signed Date ^' Application Approved by V Date Application Disapproved fot'the following reasons i Permit No. 2vu S- l 049, Date Issued 3 12 S .— 0,9 THE COMMONWEALTH OF MASSACHUSETTS lrl��e BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(h )Upgraded{ ) Abandoned( )by at , C), I<5. _.� 6�1� has been constructed in accordance r� with the provisions of Title 5 and the for Disposal System Construction Permit No.)r va)- in/_ dated 'Z Z2:4,S Installer ON.--e!t Designer fy1 .-o The issuance of this permit shall not be construed as a guarantee that the�w� �ction as designed. Date -'ifs�'" Inspecttb /�------------------ V , 1 No. 2 c'_ /i)L Fee N/I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Digozar *pgtem (Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )` System located at n., r f2,,"a.- / and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thi-permit. Date: /7 C' Approved by �/ �. /4ti,. ?(�� "EC'l �v �� /der cQk'pWIQ�j�� !U�ra �n �4eCr or Pci �9� '�/- �U ^I P,C S tr. )Gv/ ✓✓ r I G � r TOWN'OF•BARNSTABLE LOCATIONS Ma►rr► S'f . SEWAGE # 200.5 - f 0 VILLAGE \BarnS4o-L) c. ASSESSOR'S MAP & LOT - INSTALLER'S NAME&PHONE'NO. r-J K-Oj4 4/77 SEPTIC TANK CAPACITY, zSOO LEACHING FACILITY: (type) r00!acz 1 (size) 13 x 33,S' x a NO.OF BEDROOMS q BUILDER OR OWNER Claus PERMIT-DATE: PS -O S' COMPLIANCE DATE: 41]dT Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A) = 38 C<rnCM �Za ? ' C 3 =S8 .B y Riscr -B S CS - S3 BG = Go ' Q CG �ol� Commonwealth of Massachusetts /A-, 3(.7 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 3688 Main Street, Barnstable Property Address - —; Eleanor&Clyde Claus Owner Owner's Name information is required for every P.O.p O Box 1089, Barnstable. MA 02630 July 10, 2009 — _ 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. Important:When A. General Information filling out forms on the computer, COF Y use only the tab 1. . Inspector: j key to move your � ✓`J cursor-do not Troy Williamsuse the return — — key.. Name of Inspector _Tjqy Williams Se ptic Inspections rab Company Name 19 Hummel Drive Company Address - -- South Dennis MA 02660 Cityrrown State Zip Code 1508) 385-1300 _ S1682 Telephone Number License Number B. Certification' 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 ite sewage disposal systems. I am,a DEP approved system inspector pursuant-to Section 15.34 f Title 5(310 CMR 15.000).The system: s " ' . ® Passes ❑ Conditionally Passes ❑ `Fails: ❑ Needs Further Evaluation by the Local Approving Authority — ito �1"/���(ic-a •�;.� July 10, 2009 Inspector's Signature Date The system inspector.shall submit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within'30 days of completing this:inspection. If the system is a.shared system or has a design flow of 10,000 gpd orgreater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner. and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use- at that time.This inspection does not address'how the system will perform in the future under the same or different conditions of use. 3688 Main Street,Bamstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systemlage 1 of 15 - Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� 3688 Main Street, Barnstable - Property Address Eleanor& Clyde Claus Owner Owners Name -- information is required every ryp O. Box 1089, Barnstable MA 02630 July 10, 2009 page. Cityfrown State Zip Code Date of Inspection t B. Certification (cont.) Inspection Summary: Check A,B,C;D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the'failure criteria described in 310 CMR 15.303 or,in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below: Comments: System meets minimum standards set by Mass DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes or components. B) System Conditionally Passes: ❑ One or more system components as.described in the"Conditional Pass" section need to be replaced or repaired. The system, upon.completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes; no or not determined(Y., N, ND)-in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration orexfltration.or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: N/A ❑ 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 3688 Main Street,Barnstable•03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System"!Page 2 of 15 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 3688 Main Street, Barnstable Property Address "— Eleanor& Clyde Claus Owner Owners Name information is P.O. Box 1089, Barnstable MA 02630 July 10, 2009. required for every — page. CitylTown State Zip.Code Date of Inspection B. Certification (coat.) R B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: N/A. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further'Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which,will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,.if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water.supply. ❑ The system'bas 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. 3688 Main Street,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r— Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 3688 Main Street, Barnstable Property Address Eleanor& Clyde Claus -- Owner Owner's Name information is required for every P.O.p O Box 1089, Barnstable MA 02630 July 10, 2009 - - - page. Cityrrown: State Zip Code Date of Inspection B. Certification (cont.)` C) Further Evaluation is Required by the Board of Health (cont.): , ❑ The system has a septic tank and SAS and the SAS is less than•100 feet but 50 feet or more from a private water supply well**. 4 t Method used to determine distance: N/A **This.system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other,failure criteria are triggered:A copy of the analysis must be attached to this form- 3. Other: N/A D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Q ® 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: El ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a.surface water supply or El ® tributary to a surface,water supply: 3688 Mein Street,Barnstable•03108 Title 5 Official Inspection form:Subsurface Sewage Disposal Systam•Page 4 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 3688 Main Street, Barnstable Property Address Eleanor& Clyde.Claus _ Owner Owner's Name information is p O. Box 1089, Barnstable MA - 02630 July 10, 2009 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems'(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 1.00 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified. . laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form:] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. l have determined that one or more of the above failure. criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large:system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply El ® the system is located in a`nitrogen sensitive area(interim Wellhead Protection Areas—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department: 3688 Main Street,Barnstable•03108 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts L Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 3688Main Street, Barnstable Property Address Eleanor&Clyde Claus Owner Owner's Name information is required for every --- P.O.p O. Box 1089, Barnstable MA 02630 Jul 10, 2009 - - page. CityfFown State Zip Code Date of Inspection C. Checklist Check if the following.have been done. You must indicate"yes" or"no"as to each of the following: Yes . No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health r ❑ ® ,Were any.of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ 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 1.5.302(5)] 361111 Main Street,Barnstable•031011 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System•Page 6 of 15 Commonwealth of Massachusetts . _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 3688 Main Street, Barnstable Property Address — Eleanor&Clyde Claus Owner Owner's Name information is required for everyP.O.p O Box 1089, Barnstable MA 02630. -July 10, 2009 - - page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 - Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd Number of current residents: 2 Does residence have a garbage grinder? ❑, Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 08=256,000gals 9 ( Y 9 (gpd)): 07=150,000ga1s Sump pump? ❑ Yes No Last date of occu anc : Occupied .. P Y Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): NIA Grease trap present? ❑ Yes ® No Industrial waste holding:tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: NIA Last date of occu anc /use: N/A P Y Date Other(describe): N/A _ . sal stem•Pa 3613✓3 Main Street,Barnstable•03/08 Title 5 Official InsreGion Firm:Subsurface Sewage DisM a Sy qe7ar,s Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 3688 Main Street, Barnstable Property Address -- ------------- Eleanor&Clyde Claus Owner Owner's Name information is required for every P.O. Box 1089, Barnstable MA 02630 July 10,2009 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No pump since new in 2005 per BOH. Was system pumped as part of the inspection? ❑ Yes M No . If yes, volume pumped: N/A _ ' gallons How was quantity pumped determined? Reason for pumping:. N/A . Type of System: Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El 'Shared system (yes or no) (if yes, attach previous inspection'records, if any) El., innovative/Alternative technology. Attach a copy'of the current operation and maintenance,contract(to be.obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. - ❑ Other(describe): Approximate age of all components, date installed(if known)and source-of information: Tank,d-box & leaching were installed on 4/14/05 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes [A No 3688 Main Street;Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM V•y' 3688 Main Street, Barnstable Property Address Eleanor& Clyde Claus 0 Owner Owner's Name information is P.O. Box 1089, Barnstable MA 02630 July 10, 2009 required for every — page City/Town State Zip Code Date of Inspection m D. System Information ion cont. Building Sewer(locate on site plan): 18"+ Depth below grade: Y P 9 feet Material of construction: ❑cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan):" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) N/A . If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'X 10.5'X 6' 1500 gallon H-20 Sludge depth: 2' 9" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 6° Distance from top of scum to top of outlet tee or baffle Distance from bottom ofscum to bottom of outlet tee or baffle 9' How were dimensions determined? Probe Measured 3688 Main Street,Barnstable-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M a 3688 Main Street, Barnstable . Property Address -- - — ------ -- - -------- Eleanor& Clyde'Claus____ Owner Owner's Name information is is P.O. Box 1089, Barnstable MA 02630 Jul 10, 2009 required for every _ Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet.and outlet tee's were present. No evidence of leakage or damage was found. Tank was in need of pumping at this time. Inlet invert at tee is below water level but flush came through into tank ok and heavy scum buildup shows solids are getting into tank__ Grease Trap(locate on site plan): Depth below grade: _N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet-tee or baffle N/A Date of last pumping: N/A 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.): N/A Tight or Holding Tank.(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A`__ Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): N/A 3688 Main Street,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 't a 88 Main Street Barnstable. 36 Property Address P Y Eleanor& Clyde Claus Owner Owner's Name information is required for everyP.O.p O Box 1089, Barnstable MA 02630 July 10, 2009 - page. Cityr town State Zip Code Date of Inspection D. System Information (coat.) Tight or Holding Tank(cont.) Dimension N/A s Capacity: N/A gallons N/A Design Flow: - -- gallons per day Alarm present: ❑ Yes ❑ No Alarm level.. . N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A _ Date Comments (condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with Comments(note if box is level and distribution to outlets equal, any evidence of solids capyover,'any evidence of leakage into or out of box, etc.): D-box was found clean, level and in working order with equal distiribution to outlet lines through . speed levelers. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 36aa Main street,Barnstable•03108 Title 5 official Inspection Fom Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street, Barnstable Property Address --- — Eleanor& Clyde Claus _ Owner Owner's Name information is required for every P.O.p O Box 1089, arns . y Barnstable MA 02630 Jul 10, 2009 . _—_— -- - -- — page. Cityfrown State Zip Code Date of Inspection D. System Information cont. -S Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System(SAS) (locate on site plan, excavation not required):- r If SAS not located, explain why: N/A Type: ❑ leaching pits number: ® leaching chambers number: 3-500 gallon _ with 4' of stone Elleaching galleries number: 33.5' X 13'X 2' ❑ 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.): Soil was sandy. Leaching was found with a low water level with stone'found clean and dry. No evidence of hydraulic failure.or problems in the'past_wasfound at the time of inspection_ 3688 Main Street,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 s , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3688 Main Street, Barnstable Property Address Eleanor& Clyde Claus = Owner Owner's Name information is P.O. Box 1089, Barnstable 'MA 02630 July 10, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont) j Cesspools_(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A _ Depth-top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑' Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A — Dimensions N/A ' ----- - Depth of solids N/A Comments.(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A 3688 Main Street,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 13 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3688 Main Street, Barnstable Property Address - — — Eleanor 8r Clyde Claris _ Owner Owner's Name — information is required for every P.O. Box 1089, Barnstable` MA 02630 Jul 10, 2009 -- - —_� page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent'reference landmarks or benchmarks. Locate all wells:within 100 feet. Locate where public water supply enters the building.' t 1 01 0 (n}- - - - - 0 C, 71 t, { i O 3 A ;kill III _ Cl I;� t F3 , si,' it /� l= r . 53 , G t 0�;, 6 H 3688 Main Street,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 75 n ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3688 Main Street, Barnstable Property Address Eleanor&Clyde Claus Owner Owner's Name information is required for every P.O. Box 1089, Barnstable MA 02630 July 10, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water - ® Check cellar ❑ Shallow wells Estimated depth to high-ground water: 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: 12/11/04` Date ® Observed site (abutting property/observation.hole-within 150 feet of SAS) ❑ Checked with local Board of Health explain: ❑ Checked with local excavators, installers-.(attach documentation) ® Accessed USGS database-explain: t AM 247 Zone B 22.9'. 2.2, adjustment You must describe how you•established the high ground water elevation: Soil was sandy: Test hole 11.5' below bottom of leaching showed no water found at 17.0'. Groundwater adjustment in area at the time of inspection was 1.4'. Bottom of leaching at 5.5'was found not to be located in the high groundwater elevation at the time of inspection. 3688 Main Street,Barnstable•03/08 l"ills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 t 9/16/03 Notice: This Form Is To Be Used For the Repair.Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I,bxr" m, ,m!qw hereby certify that the engineered plan signed by me dated �� concerning the property located at �8 N � tlf$ 60 meets . all of the following criteria: • This failed system is connected to a residential dwelling only. There.are.no commercial or business uses associated with the dwelling. • The.soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: a A) Top of Ground Surface Elevation(using GIS information) J& B) G.W.Elevation +adjustment for high G.W. DIFFERENCE BETWEEN A and B A f 0/1 SIGNED DATE: Jc a� NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc - Town of Barnstable yP�pFtHE Tp� o� Regulatory Services Thomas F.Geiler,Director sn�uvsTnBre, 9 HAS& Public Health Division t63i �m arm A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 113010 Designer: �� ✓� �"`°9 Vt k- 'S' Installer: c_ j ' Address: . Ro. g811 Address: 1y "� r•ra'lw�, A On CL-�- 2als e r , 'IA' ,_4 was issued a permit to install a (date) RD Vin C sttller)—r septic system at ��$ MA 1N �Tf.t;e r; �W57AU&ased on a design'drawn by (address) • meqlw dated ;CeZ 1,2� uo s . (designer) 1--certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. TAu-JK LOU 10 t4 WIGS CNAIJ4F_-Q I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local ,e ations. Plan revision or certified as-built by designer to follow. N OF iyq D R N staller's Sign a 1140 STF-?' Q S^'NITARIPN T 1 (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH -TMS, FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. b - Q:Health/Septic/Designer Certification Form TOWN OF BARNSTABLE LOCATION �� ,q,;,� 4— C SEWAGE # VILLAGE gR,@,J�lt�a�E ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /Gao G,9L 0�cie/1 �oe� TA.1� LEACHING FACILITY:(type) (size) NO. OF BEDROOMS Z_PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER_.&"t DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ttj PC d R�EA 1 _ \, y TOP OF 3 ► STANDARD NOTES ' FOUNDATION ^ EL .XD 1 THIS PLAN IS FOR THE INSTALLATION OF A SEPTIC SYSTEM Raise coYP,r to withi 6" of ) N.G. GROUND SURFACE E _�'2_Sb finish ga ache install risers as needed p .n rn ) ALL INSTALLATION P '(�CEDURES A}4i'J MATERIALS SHALL CONFORM TO 310 CMR 15.000, THE STATE ENVIRONMENTAL CODE, l' • _' ,, GROUND SURFACE Elm __��l' � (,,n�c TITLE 5, AND THE TOWN OF �� ��rZ7_�:7_`��------ SUBSURFACE DISPOSAL REGULATIONS. MIN - -�`�-` r � Q ,�: l - � �( 3) NO DETERMINATION 1�hS BEEN MA1.3L AS TO COMPLIANCE OF A MAILABLE PROPERTY INFORMATION yv11 H REt,ORD�� DELDS OUTLET PIPE LEVEL 4l\5� r� �°'3 0� ►`� (`q `'e / T in A f-d��!Q _.. - •.. - ii FIRST TWO FEET VENT REQUIRED �k1'L. -- 4 TOWN WA NOT SERVICE THIS PROPERTY M OR ZONING REGULAT ONS. •�3 2 MIN-3 MAX TOP EL � ) INVERT L i MIN 2' LAYER DOUBLE WASHED 5) THERE ARE NO E NG WE 200 OF THE PROPOSED SOIL ABSORPTION SYSTEM D-BOX 1/8'- 112' STONE N ProposedxistinB 10" ---- 6) ALL COVERS OF SYSTEM li COMPONENTS SHALL BE BROUGHT TO WITHIN 6" OF FINISHED GRADE EFFECTIVE 3` 7 ALL SYSTEM COMPONENTS SHALL RLMAIN ACCESSIBLE FOR INSPECTION. NO STRUCTURES SHALL BE LOCATED DIRECTLY I q WSTALL .__ SIDEWALL ; 4d•D3 m GAS INVERT E.L s� s7o1v� BASE =L � � = 11 �1 1 t \c� UPON OR ABOVE THE COMPONENT ACCESS LOCATIONS, WHICH WOULD INTERFERE WITH THE PERFORMANCE, ACCESS, INSPECTION BAFFLE INVERT EL INVERT EL 1 G h 1; 3/4'- 1 112' DOUBLE PUMPING OR REPAIR. Proposed , WASHED STONE 8) NO DRIVEWAY, PARKING OR TURNING AREA, OR OTHER IMPERVIOUS AREA SHALL BE LOCATED ABOVE A SOIL ABSORPTION - D 6" STONE BASE IN EL D - Box INVERT EL p&S C AST �K4 CRAM AM � t�� �' BOTTOM EL SYSTEM, EXCEPT WHEN VENTING H11S BEEN PRO VIDEO. (Typical) / Proposed Existing W '� (� N / ,�, 9) SEPTIC TANKS, GREASE TRAPS, DOSING CHAMBERS AND DISTRIBUTION BOXES SHALL BE PLACED ON A 6 STONE BASE 1 Gal Septic Tank ► 1 - EL �V ADJUSTED GROUND WATER TO ENSURE STABILITY AND PREVENT SETTLING. I � P (Typical) -° ar ��J = �ns _ EL N EXISTING GROUND WATER 10) OUTLET DISTRIBUTION LINES SHALL REMAIN LEVEL FOR A MINIMUM OF THE FIRST TWO FEET OF THEIR LENGTH. 1D1N Lo I N ZU G `( U 11) ALL SYSTEM. COMPONENTS SHALL B�f, CAPABLE OF WITHSTANDING II 10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 r I EL BOTTOM OF TEST HOLE` OF DRIVEWAYS OR PARKING OR TU7`?AT AREAS, IN WHICH CASE H-20 COMPONENTS SHALL BE USED. _. 12) ALL BUILDING SEWER LINES SHALL TIAVE AN INNER DIAMETER OF 4" AND SHALL BE CAST-IRON OR SCHEDULE 40 PVC. 4 13) THE DEPTH OF THE TOP OF ALL SYSTEM COMPONENTS SHALL NOT EXCEED 36" UNLESS VENTING HAS BEEN PRO TIDED. 14) IA' THE AREAS OF EXCA VATION, EXISTING GRADES SHALL BE REESTABLISHED UNLESS NOTED AS PROPOSED CONTOURS. S 68°19'00 " E ,` ,NIF' 15) IF SOILS ARE ENCOUI,'TERED DURIAr THE EXCAVATION OF THE SOIL ABSORPTION SYSTEM, THAT DIFFER NOTABLY FROM THE DEEP OBSERVATION HOLE LOG, CONTACT THE ENGINEER BEFORE PROCEEDING, �l6, F�or�/Zon 6. 37' Handy Map 317 Pel 22 16) CONTRACTOR TO VERIFY LOCATION OF ALL UNDERGROUND UTILITIES. EXCAVATION NOTES R — 70. 9�- L = 40. 9c,J ' ' 1) EXCA VA TE ALL ILIA TERIAL ABO VE SOIL HORIZON C SEE .DEEP OBSER VA TION o TO O f HOLE LOG) AT APPROXIMATE ELEVATION 9 3. 3, FOR A LATERAL DISTANCE OF 5' S 6810 30 E' 202 90> �� cl 8 (WHERE POSSIBL ) IN ALL DIRECTIONS BEYOND THE OUTER PERIMETER OF THE LEACHING AREA. k (53 7) f (�° / f Frn d ClC . 2) FILL MATERIAL S'FIALL CONSIST OF CLEAN GRANULAR SAND, FREE FROM ORGANIC MATTER AND OTI[E'R DELETERIOUS SUBSTANCES, WHICH MEETS THE TEXTURAL `F .., •' CRITERIA PUT FORTH IN SECTION 15.255(3) OF TITLE 5. Map 31 Parcel 24 Clump asap es f (35:s) 3) SCARIFY THE BOTTOM SURFACE OF THE EXCA VA TION PRIOR TO PLACEMENT 39,560f Sq. Ft. (3s.$) �, ,� 16„ OF FILL INTO TI.L RETAINING STRUCTURE. Maple 4) PLACEFILL ONL r WHEN BOTTOM SURFACE' IS DRY, ..- - 10" �. �S`�ffaple 30" f r' Mapl O O DESIGN DA TA DEEP OBSERVATION l 3) i HOLE LOG 7 ,! 5• t.y her of Bedrooms: #1 s Test , _ � � Number st Hole 5 Y -r� S'p o p (E { C/� --� j . H le. Garbla.ge Grinder.: ]�] - ar \ " — �/g� ,, 1 V 0 D p{h ev soil Soil - Soil I . 3 f Fin) 7(ft) Horizon Texture Color ,. .7 i USDA Munsell _ T C. ) Des"- Flow J c,. 1c. J. 6 .Spruce (i1G Gal/BR/Dap x Number of BR) , 1 _.,.. —Y ` � - � N F r- ! c� �t � d ;y,. i'.�..c,,�'� �'A�,yl _ . ,See L. C. Plan , 5 24 - 0 3v. l.�r ,I S r 3. Z 9) � " 3 ) Sep Tank: j � C�A�C �- t? 6 (� D�TC Realty Trust • 1- ., ,_ IL too lov 34901A I �` �' _ ba /26 y.st Yr SILT- 1 ° • 1) �) - (Minimum = Design Flow x 260%) I (3�- � '� � l�la 317 Pc1 25 U .. ►r �► j I - Igo �o a c,n Ae 3y.5) Leachir�.g Area: S1(°te Wall: Deep Obs Hole Date: N F �) � ��Soil Evaluator: D, MG e.� `J GS 7 z- !i' v 75 (2 Sidewalls x _ul —Ft x Ft) + PerceSRate:H/`dry .Porch } - 4^_Ft 66 Soil Survey Description: CARVER Ma 31 / 1'CI i (�2` , (36,7) / (36,1) \ I (,2 Endwalls x ---- x ) I Geologic Material: OUTWASH 1 © I / Depth to Standing Water: NA �I J ro v1y � Bottom: Depth to Weeping Water: NA / \ Depth to Mottlin Color: NA P ) 0� WOOD' I 9) 3 �c t'j 3y•6) ' I I � (3 � Cesspool ------Ft X __�_Ft) � � ✓ ✓ • Est seasonal High GW: NA G7� Exist USGS Observation Well: NA Long Term Acceptance Rate (LIAR): 0 �4 Date of Last Measurement" NA /(3 0) Nv `� �(36 / I Leac.f:iing Area Design Capacity: � l. qDXD,�y (Siriewall Area + Bottom Area) x LTAR = 469 P Bldg #3688 2 \ ► o W 4 Bedrooms Plan Reference LC Plan 34901A PB 180 PG 103 7iOF EL 43.8 ------------------------------------ \ �: C145818 o �- 36 Title Reference ----------------=---------- Flood Zone Fema 250001-1D (3 9) -------- Lot Size 39,560 f Sq. Ft.�24 Zone C 42.220 SITE AND SEWAGE .PLAN MHB . PROJECT LOCATION 3688 Ma1n' Street ;iFI1 C� CB ; Cn t Bll C FndBarnstable; ��1A Fnd AfHB --- �� 30 w 1\Fnd 1) W (�l0'7) 37.7) I �:5) CB Cnt Bk UP 166 �2. � I 3 ��) � _ _ ;_ N cy5o 7 ; (3 c° Ga,►>,, 317 23 t 24 3� 30 9) i o ,r..----- C�� ASSESSORS MAP LOT (39. ; - N 70 31 '30" W 14 6. 00' 'I UP (A°' UP 167 33.1) 168 r _ _ pG(J 5 siae Pik _. % s .._.._ .._.:. — — —. _ 2.1) L APPLICANT �✓d ( ► .- Cl_v e Ellie Cla us PO Box 1089 11 AIAT STREET a 3688 1�1�`a1�7 Street (Rte 6A� Route 0 Z 1 �E' Barnstable, MA 02630 ' a ter Main ��— � �� PREPARED B Y Exist Hydrant �a 1 - :Iv lVI ' " �e C-e„ Tag _.1 • � � � d z S37 LOCU . - - � �TtA OF dfq��� ► its 1 I':( DARRE�J � �;a �"�ss�� SCALE. 1' = 20' DATE. ��.6RD i MEYE V. s A. e, o. 1 jj'Q ST01NE �c V. :1 No. 28980 REV. V ' AND- a� D WG NO. 3179 SHEET 1 OF 1 I ' - - _