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Home My WebLink About3940 MAIN ST./RTE 6A(BARN.) - Health 3940 MLhin Street/Rte 6A (Bern) Barnstable . P A = 335.:.023 Y ° e n v ' r i e C I i n y Ir TOWN OF BARNSTABLE LOCATION �� O SEWAGE # VILLAGE&LM��qASSESSOR'S MAP & LOT INSTALLER'S' NAME & PHONE NO. SEPTIC TANK CAPACITY I,coo GZJ LEACHING FACILITY:(type) ,�C)CO (size) . NO. OF BEDROOMS 3 PRIVATE WELL O UBLIC WATER BUILDER OR OWNER -2-L" DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �g � Z� � M _� a 6 d (�f �� ti ' i i2,� � � i f TOWN OF BAITI NSTABLE -- 0 I.v `ATION //L AK4�� SEWAGE # `/�� VILLAGE ASSESSOR'S MAP & LOT •�TnT ---'-'-�.�`— ^•+vn rt�r t�rr� -�/.9.�CJC//�G� SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) —' (size) y NO. OF BEDROOMS C� BUILDER OR 0WNER�y�/>��/s/�l PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility. (If any-wells exist on site or within20Q feet of leaching facility) , `1 Feet Edge of Wetland and hin Faci '.ty (If y Hands exist ;� within 300 fe f k" lity) Feet Furnished by r �J � I °1 A, / � a / INI Date: 3 /2,!'�l/ 1 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: (j BUSINESS LOCATION: i INVENTORY MAILING ADDRESS: ,2. 1;/.7V 1.3 �, � � A4aa-ejl j,l TOTAL AMOUNT: TELEPHONE NUMBER: _ Oe-- 77/P — 7d!j!j D�l�37 CONTACT PERSON: eA EMERGENCY CONTACT TE EPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, # 2 heating oil ❑ NEW ❑ USED . Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes . Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Ap cant's Signature �affs Initials I YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business.Certificate that is required by law. DATE: Fill in please: i � J APPLICANT'S YOUR NAME/S: Qyl Kw BUSINESS YOUR HOME ADDRESS: s TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF-DOW BUSINESS -'1 O TYPE OF BUSINESS ,4%-ie ' IS THIS A HOME OCCUPATION? YES NO 2 ADDRESS OF BUSINESS J MAP/PARCEL NUMBER 3-3 _(Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO I MMISSIONERR OFFICE MUST COMPLY WITH HOME OCCUPATION This individual has been or e f any pe i q "Leents that o this type of bu ss. ULES AIVD REGULATIOf�s F. COMPLY MAY RESULT IN PI S., TO u ed SignaturN CO MENTS: C-�C��-C o 2. BOARD OF HEALTH This individual ha e n informed of the per requir ments that pertain to this type of business. �S' G _Mpl`i�Wl'I`M'AL :A thorized Signature** �F[1OU VI�31HVlI..sno02i1t�dH- COMMENTS: ORDOW.-MATERIALS REGULATIONS `W .1.16M.41Q„y., 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: / Wy PnWe ® (A BUSINESS LOCATION: 3!6�{D ]'��,ih .117 G!e /7 0�2123 INVENTORY MAILING ADDRESS: Paa /3 3 scd -&A &22/p 3 7 TOTAL AMOUNT: TELEPHONE NUMBER: Soo— 3&2- - 760&�( CONTACT PERSON: ke'I'l4 6 a EMERGENCY CONTACT TEL .PHONE NUMBER: S%tee_ MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous_waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) _. Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils., Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS - DATE: 9J121o2__-- PROPERTY ADDRESS: 3940 Route 6A - ----------------------- --Cummaquid,Mass__------- 02637 On the above date, I inspected the septic system- at the abov qlaTMIVED This system consists of the following: 1 . 2-1 000 gallon precast leaching pits in series. ( 6 'X9 ") SEP 2 5 2002 TOWN OF BARNSTABLE HEALTH DEPT. Based on my inspection, I certify the following conditions: 2. This is not a title five septic system. -- 3. This is .a sewage system. 4. The sewage system is in proper working order at the present time. 5. Pumped the main leaching pit.Heavy scum & solids layers were present. Garbage disposal is present. Waste water is 60" below the overflow leaching pit. invert.Stain line is 49" below the invert pipe. SIGNATUR - Name: J . P. Macomber Jr. COrtipany : Joseph P .- Macomber & Son, Inc. Address :-_Box -6 6 ------------ Cen � v_ill�,_ba -Q2632-0066 F Phone : 508-775-3338 --------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfield:s Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • COMMONWEALTH+OF MASSACHUSETTS°.' r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 , OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS° SUBSURFACE SEWAGE DISPOSAL-SYSTEM FORM PART A CERTIFICATION Property Address:3940 Route 6A Cummaquid,Mass,. Owner's Name:_Mariam Thomaj an Owner's Add resse-Box 171 s CummaQuid,Mass 02637 Date of Inspection: 9/1 2/0 2 Name of Inspector: (please prin0ioseAh P.Maeomber Jr: Companv Name:,7 P MacnmhPr & Sbn Inc. Mailing Address:R�X 66 Centerville,Mass. 02632 Telephone Number: S08-775-3338 CERTIFICATION STATEMENT. I certify that 1 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. l am a DEP apprpved system inspector pursuant R�PFa ction.15.340 of Title 5(MO CMR 15.000). The system: a sses 4 -- ..Conditionally Passes Needs'-FunherEvaluation by the Local Approving.Authorir�. ;. Fails Inspector's Signature: Z Date: �� ''� The system inspector shal ub7mita�copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. if the system is a shared system;or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should`be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes anal Comments , j ****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.unde"r the same or different b conditions of use. Title 5 Inspection Form 6/15/2000 page 1 I _ . Page 2 of I 1 OFFICIAL INSPECTION FORM ry— NO T FOR VOLUNTARY ASS ESSMENTS SMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3940 Route 6A, Cummaquid,Mass. Owner: Mariam Thomaj an Date of Inspection: 9[12 0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A: ystem Passes I have not found any information hick 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 sewage system is in properworking order at the cracant time- B. System Conditionally Passes: r 2,,�/l 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. �iPI'he e tii is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, e ibixh 'ts substantial infiltration or exfiltration or tank failu re is imminent. System will pass inspection if the exististg 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: e, Observation of sewage backup or break out or high static water level in the distribution bo due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced . obstruction is removed distribution box is leveled or replaced ND explain: i /j/d 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: Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3940 Route 6A Cummaquid,Mass. Owner:Mariam Thomaj an Date of Inspection: 9/1 2/0 2 C. Further Evaluation is Required by the Board of Health: V 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 Im 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: D 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. 1(b The system has a septic tank and SAS and the SAS is less than 100,feet but 5 feet or more from a private water supple well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds-indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: ' Thi G is a�sPwa�c a system. The system consists of ' �2_1 OnO qA 1 1 r)n nrPcast . leaching pits in series. ( 6 ' X9 ' ) 3 Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION (continued) Property Address: 3940 Route 6A _ C' tim�uir3�Mass _ Owner.Mariam Thomaf an Date of Inspection: 9/1 2/02 D. System Failure Criteria applicable to all systems: You must indicate "yes" or"no"to each of the following for all inspections: Yes No i ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool �ischarge 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 bove outlet invert due to an overloaded or clogged SAS or _ 1�cesspool I Q�_ 4(J�f y t squid depth in Qesspeel is less than-6"below invert or available volume is less than ''A day flow Requ xed pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ny portion of the SAS, cesspool or privy is below high groundwater elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ,water supply. 4�/kny y portion of a cesspool or privy is within a Zone 1 of a public well. 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. lThis system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] . (Yes-'No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design (low of io,000 glad to 15,000 . gpd• You must indicate either"yes"or"no" to,each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no - the system is within 400 feet of a surface drinking water supply :� the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR I 15.304. The system owner should contact the appropriate regional office of the Department. f 4 Page 5 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ._ Properry Address: 3940 Route 6A Owner: Mariam T omal an Date of lospectioo: 9 22 02 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No mptng information was provided by the owner, occupant, or Board of Health Were any of the system components,pumped out in the previous two weeks ? ' Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? !/ 'Alas the site inspected for signs of break out ? Were all system components?;4Clucling the SAS, located on site ? GAG `' Were the septic tank anholes uncovered, opened, and the interior of the tank inspected for the condition, of the baffles or tees, to of construction, dimensions, depth of liquid, depth of sludge and depth of scum Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no - Existing information.For example, a plan at the Board of Health. _ Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) S Page 6 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:3940 Route 6a Cummaquid,Mass. Cummaguid,Mass. Owner: Mariam Thomajan Date of Inspection: 9 f 1 2/0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms): - x))e9__oV el'4� Number of current residents: Does residence have a garbage grinder(yes or no):/G Is laundry on a separate sewage system (yes or no):,f L:�) (if yes separate inspection required] Laundry system inspected (yes or no): r Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage (gpd)): 2001 —7 2, 000 gallons=1 97 . 26 GPD Sump pump(yes or no): M 2001 -80, 000 gallons=21 9 . 1 8 GPD Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): z),47 gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):,40 Industrial waste holding tank present (yes or no):Z�4 Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Not available Was system pumped as part of the inspection(yes or no): If yes, volume pumped:,,6�id gallons -- How was quantity pumped determined? Reason for pumping: Heavy scum & solids layers were present. TYPE OF SYSTEM 100 ptic tank, distribution.box, snRit absorption system Ingle sesspeel A50fh.' /Tt _Overflow-eesspovl I ��ii, 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) '16�) Tight tank.-VO Attach a copy of the DEP approval , Other(describe): =A Approximate a�al cmpQnenl,, date installed (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):Ie�y 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3940 Route 4,a Cummaguid,Mass_ OwnerMari am Thoma-i an Date of Inspection: 9 1 2/02 BUILDING SEWER (locate on site plan) Depth below grade: a< Materials of construction: _cast iron AP40 PVC other(explain): 4" Orangeberg pipe Distance from private water supply well or suction line: Comments(on condition ofjoints, venting, evidence of leakage, etc.): ,mints appear tight -No evidenne of leakage-The system is vented through the house vents. SEPTIC TANK.*6&(locate on site plan) Depth below erade: A1,4 Material of construction:4�4concrete,1)4 metal,4fiberglass"olyethylene &, ther(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no)4(attach a copy of certificate) Dimensions: AM Sludge depth: 14llo Distance from top of sludge to bottom of outlet tee or baffle: 4U Scum thickness: Distance from top of scum to top of outlet tee or baffle: XA Distance from bosom of scum to bottom of outlet tee or baffle: /t/O Hoµ.µere dimensions determined: m itJ/1 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):- Septic tank is not present_ -The first leaching pit should he pumped every 2-3 years-Pit acts- as septic tank-Contains soild waste in place. " GREASE TRAP .(locate on site plan) Depth below grade: �Q Material of construction:,04 concret;ametal�&fiberglasslJ�polyethylene,04other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease ap is not C rPsgn _ 7 Page 8 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3940 Route 6A Cummaquid,Mass. Owne'MAriam Thomajan Date of Inspection: 9119102 TIGHT or HOLDING TANK,a&u (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: _ 4 Material of construction: /�i concrete 4ZI Z_metal Wfiberglassd//I Polyethylene li± other(explain): �A Dimensions A/4 Capacity: ,01 gallons Desien Flo" A14 gallons/day Alarm present (yes or no): ,tA Alarm level: ,//� Alarm in working order(yes or no):44 Date of last pumping: Comments (condition of alarm and float switches, etc.): Tight or holding tanks are not present. DISTRIBUTION BOX :K, (if present must be opened)(locate on site plan) . Depth of liquid level above outlet invert: .60 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.): Distribution box is not- present. PUMP CHAMBEWyi> (locate on site plan) Pumps in working order(yes or no): �Nd Alarms in working order(yes or no): —' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): E?ump chamber i s not present- ell 8 Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address3940 Route 6A Cummaauid,Mass. Owner:Mariam Thomaj an Date of Inspection: c).11 2.102 Zlocate SOIL ABSORPTION SYSTEM (SAS): on site plan, excavation not required) 2-1000 gallon precast leaching pits. 6 ' X9 ' If SAS not located explain why: T.nrtated- see page1 t1 Type leaching pits. number: li9 leaching chambers, number: !� leaching galleries,number: leaching trenches, number, length: a �11�) leaching fields, number, dimensions: overflow cesspool, number: 4 ti innovative/altemative system Type/name of technology:� 77 Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy Gana to clay mix to fine sand No signs of hydraulic failure or ponding- Soils are dry Vegeation is normal CESSPOOLS(cesspool must be pumped as part of inspection)(locate on site plan) NuNber and configuration: Depth—top of liquid to inlet invert:tiA Depth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): CPGGrinnlG are not present - - - . PRIVY4,& ,(locate on site plan) Materials of construction: Dimensions: Depth of solids: 6j Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy iG not jrPGPnt 9 Pq( 10 0( 1 r 0PPICLA.1.. INSPECTION FORNf — NOT FOR YOLVNTA.RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSA! SYSTEM,FNSPECTION FORM PA RT C SYSTEM INP0R.v1 TION(conIinJ'cd) Paoprrry ndofa��i 3940 Route 6A CUMMaaU' Mass. C+ ocr, Mariam I omaja r Disc ollnipcn;oo: 9 02 SKITCH Or SCWACE DISPOSAL SYSTEM P- Ao•�oc � ikcic� of the icHi�c 4iipoici cyitcm includln •tic7 l0 11 Ic671 by ocn<r✓nvki to ..aur wiihin I00 fcci: Loccic whgrc pvblic wiicr J pPly Cnnccri`U`a brv;IQjn`+.nCmux� o W , 41 i 0 # Page I I of OFFICIAL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:3940 Route 6A Cummaquid,Mass. Owner:Mariam Thomai an Date of lnspectiong/12/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 ' feet Please indicate (check) all methods used to determine the high groundwater elevation: NO Obtained Gom system design plans on record - If checked, date of design plan reviewed: YFS Observed site (abutting property/observation hole within 150 feet of SAS) Uo __ Checked with local Board of Health-explain: A�/Q Y-Es Checked with local excavators, installers- (attach documentation) Ya Accessed USGS database-explain: http,//town harnStale.Ma.us. You must describe how you established the high ground water elevation: Used: Gah>:ety & Miller Mod 1 1 116194 rrnund P1evatinnc Ahnup Sea 1e el Used: USGS: nnservati nn well dates June 1992 Used: USGS, Tarhi ni ra 1 Rill 1 et n 97 000 1 Plate #2 January 1992��Ani�a_� rancres 19N ut-vrSF C' water aleyati ns; . Leaching Pit 81 ..Cc( � 22 ' I Groundwater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the (caching pit and the adjusted groundwater table is feet. 9. 60 ' 11 "RZT.-^RI'T�T{TTT:lRt•!{1TTrJTr. STT.SfR:`.T•T:TTT:TTTi'f.•ITiI•R'1"'{Ti 1",CTRTi RZ, . r• .TT`T:t�.T.T^...�• r-... 1 TOWN. OF Barnstable BOARD OF HEALTH f SUIIHUACF 9F.WA(;F, DISPOSAL ,SYSTEM INBi'FCTION FORM - PART D •- CERTIFICATION .•••T•'•^T••••• -�.tl ^.�:T{T1I'R.'1Ti T'{Ti'.1TTTf)TI'11t�.•.'}"It1TTlST'1T1R^•TRTlTCi'Ai Ri'S.RT'iTC'M1Tt fiTTigTITTTf2p� -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 3940 Route 6A Cummaquid,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # 6P OWNER' s NAME Mariam Thornaj ari PART D CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. . COMPANY NAME J.P.Macomber & Son Ine:," COMPANY ADDRESS Rnx 66 Cen_terville,Mass. 02632 Street Town or City State lIF COMPANY TELEPHONE (508• 1 775 - 3.338 FAX (508 1 790 - 1578 CERTIFICATION STATEMENT - a I certifythat I have y p _ personally inspected the sewage disposal system at this address and that the .information ' reported is true , accurate , and omplete as of the time of inspection6 The `inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance -of on- site sewage disposal systems , ` Check one � stem; y PASSED The inspection which I have conducted has not found any in-formation which indicates that the .'system fails ,to adequately protect public health or Lhe environment as defined ' in 310 CMR 15 . 303 . Any failure criteria not evaluated are as state d" in. the FAILURE": CRITERIA section of this form. System FAILED* _ The inspection wiiicl, I have coraucted has found that- the system fails to Protect the public health and the environment -in accordance with Title 5 , 3.10 CMR . 151, 303 , and as specifie.ally noted on PART C - FAILURE CRITERIA of this inspection form , 1 In �• s ecto r Si Hato �. P r S D a �., j ne copy of this certification must be provided to the OWNER, the BUYER ` ( where applicable ) and the BOARD OF HEALTII. * If the inspection FAILED, the owner or"'oparator shall u pgrade ' the eyetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3,10 CPJR 15 . 305 . partd .doc