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Home My WebLink About4027 MAIN ST./RTE 6A(BARN.) - Health 3 4027 MAIN STREET, CUMMAQUID 4 A=335-030 i s �t v t Y 1 r r: m m i a� * " r F ,.•_ � •R ,• - - , /1 � y, 1 �)'a 4 , �T� ,1r a .. ( yr e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is q required for every Cumma uid MA 02637 6/18/2009 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, use only the tab 1. Inspector: key to move your cursor-do not Brian K. Tilton use the return Name of Inspector key. The Building Inspector of Cape Cod �y Company Name PO Box 307 Company Address I Eastham MA 02642 Cityrrown State Zip Code 508-255-9343 S14392 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails [] Needs Further Evaluation by the Local Approving Authority 6/18/2009 (dectto�rrs 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. w 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s ,M 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is q required for every Cumma uid MA 02637 6/18/2009 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: All components in place and functioning as designed, System is in good shape. 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 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. 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 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is q required for every Cumma uid MA 02637 6/18/2009 page. City/Town State Zip Code Date of Inspection . B. Certification (cont.) 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: N/A 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 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. 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is q required for every Cumma uid MA 02637 6/18/2009 page. City/Town 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**. Method used to determine distance: **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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is q required for every Cumma uid MA 02637 6/18/2009 page. City/Town 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 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. 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is 4 required for every Cumma uid MA 02637 6/18/2009 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ 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)] 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is q required for every Cumma uid MA 02637 6/18/2009 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 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 '07= 93 gpd, '08= 9 ( Y 9 (gpd)): 80 gpd Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions; Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gaiions per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A Last date of occupancy/use: N/A Date Other(describe): N/A 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 I Commonwealth of Massachusetts w u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is q required for every Cumma uid MA 02637 6/18/2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is 4 required for every Cumma uid MA 02637 6/18/2009 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks or clogs Septic Tank(locate on site plan): Depth below grade: 12"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: 1111: x 66" x 47' Sludge depth: 11 Distance from top of sludge to bottom of outlet tee or baffle 19" 4" Scum thickness Distance from top of scum to top of outlet tee or baffle 6„ i Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Accu-Sludge, Baffle Stick and Tape measure 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 I— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is q required for every Cumma uid MA 02637 6/18/2009 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.): Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 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 4027 Main St.t5insp-03/08 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 G M , 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is Cumma uid MA 02637 6/18/2009 required for every q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: N/A Capacity: N/A gallons Design Flow: N/A 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 i *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 None installed 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.): There is no D-Box in this system Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 f , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is a required for every Cumma uid MA 02637 6/18/2009 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 Infiltrators in L pattern ❑ 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.): Three High Capacity Infiltrators in series in an "U pattern to clear lot Iines,lawn over top, no evidence of breakout or hydraulic failure, <1" Ponding in first chamber under inlet. 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is q required for every Cumma uid MA 02637 6/18/2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is Q required for every Cumma uid MA 02637 6/18/2009 page. City/Town 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. DWELLING SLOPE A B DECK 2 I 3 NOT TO SCALE A l= 31, B 1=1 7, A3=23' 83=266" 4027 Main St.t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4027 Main Street Property Address Robert T MacNamee Owner Owner's Name information is 4 required for every Cumma uid MA 02637 6/18/2009 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: 7+ 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: 3/10/1999 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: Asbuilt card shows on file with BOH states 20' to ground water, Sump pump holes in basement no water at 7' at time of inspection. 4027 Main St.t5insp-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 I Cape Cod Commission: USGS Well Data-May 2009 Page 1 of 2 United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties,the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month.They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with T Cchric-al 'Bu flefin 92-00 : Est€matior. ofI'lliaii Gi-ogiidX-3atei� -,-eyels for Construction and Land use to predict high groundwater levels. For your convenience,we've also provided links to USGS national and state data. See the last au=:.=3 a in the table and the footnotes below. To see what's happening in real time at a separate well in Brewster, visit the USGS site: I,JS6S -?1,46,01.07{_0-1490i 1 t ,;,- For further information about any of the data or links on this page,please contact;Iy-dry=cF��i4, kiabridic 43€€1 ii at the Commission offices(508-362-3828). May 2009 Water Record Record Departure from Location Well No. Level* HighX Low* Average* nlr� _ �x AIW Monthly Overall Barnstable 230 22.4 20.5 26.6 0.3 1.2 t?3�% {'- ?tE 4= :<<:► Barnstable 24W 22.6 20.5 28.6 0.9 1415A07€11 6 i00 Brewster BMW 21 9.6 6.9 13.6 0.0 0.5 14 S 180700-.() i?1. Chatham CGW138 23.2 20.9 26.6 -0.2 Mashpee M1W 29 7.4 5.6 10.0 0.1 1.0 -i' >` t? 't 21:i 910 Sardwich SD2 46.8 45.8 48.2 0.0 0.4 41441 80702-1160 Sandwich �DW 49.E 45.8 55.1 0.2 0.7 _ Truro TSW 89 11.6 10.2 13.0 0.1 0.4 4-2Q20 07Ot?-901 Wellfleet WNW I7 10.1 7.3 12.8 -0.3 0.4 t t 06 41540I1 BOLD New Monthly High * Measurements are in feet below land surface. ** Measurements are in feet above mean sea level. !!S(T .!)a0oI) 1 s.lalah ise provides historic data,hydrographs,and site maps. http://www.capecodcommission.org/wells.htm 6/3/2009 HIGH GROUND-WATER LEVEL COMPUTATION Date: Site Location: q-DO'7 ��' Permit: M i Phone: Owner: contractor: y; � C. Phone: C Notes: STEP 1 Measure depth to water table / r� to nearest 1/10 ft. � 1 g kc> lP� (depth is in feet below land surface) Date: mrn/dd/yy feet below is STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: �Z�L A) Appropriate index well B) Water-level range zone STEP 3 Using monthly "Current Water Resources Conditions"determine current depth to water level for index well_ 1 'T rnm/yy STEP 4 Using Table of Potential Water Level Rise for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level P zone (STEP 25) determine water-level adjustment STEP 5 Estimate depth to high water by subtracting the (� water-level adjustment(STEP 4)from measured depth to water level at site(STEP I)- NOTE* Tables 1�9 "Potential water-Level Risse"are attached as worksheets to this file. monthly Index well data: www.capecodimmission.org/wells.htrni i , � .. h n tP r j Ap Ac Ilb At it ' ,�arw f Nk SAC l .. Al _ 2 4� T?Ft,V j ,g : A a::� C �..• Q �, .m� � „r 0 s' 3 ♦ -M y:.J�(� L. •+P 'f �Ts FF�� '� 3 ��., �� fi¢ "1 � ♦. �^.e��+'-;l red `� d .$'�``' � La'. ♦ �� /'"tea 3r � �`' �t v\ N mi '1� .��• .,s; '4.- "� 3� � an�N4 t ,> � �'y Y ea�R. vim£\� ♦r ��- ,, f � q \ . yk y. d; WTR j 19 VL Pik" r,AL 1.7 It , YqQ 'dQ'3 �fr # 4�F 402Z MaimSt, Year o.uth,,MA'02 Ale '' ` ry `�R'.a `..w„ ,tt�e , 17 . " �«`` � a `tit* t�� .F u A m quiddill tr qr+.� - f 4 AL All * ; Q 24fl9 UBC nsus 6Ureau w r �magc?ry t7atc: J�1;29„2007' 41`42'44.$9"N ; T9`i6'3.V V, e ev 46At ;t ye alt 3345,it.-;_ o .. COMMONWEALTH OF MASSACHUSE'ITTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION d t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 4027 MAIN ST CUMMAQUID,MA 02637 Owner's Name: MR. MULLER Owner's Address: 4027 MAIN ST CUMMAQUID, MA 02637 Date of Inspection: 6/9/01 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS RECEIVED Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 JUN 15 2001 CERTIFICATION STATEMENT TOWN OF BARN;i AGs:E HEALTH DEPT I certify that I have personally inspected the sewage disposal system at this address and that th 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: X Passes _ Conditionally Passes _ Needs Furthirtvaluation by the Local Approving Authority Fails Inspector's Signature: t Date: 6/9/01 The system inspector shall submit 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 and Comments SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****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. w 4 Page 3 of I l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4027 MAIN ST CUMMAQUID,MA 02637 Owner: MR.MULLER Date of Inspection: 6/9/01 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(l)(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 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 n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4027 MAIN ST CUMMAQUID,MA 02637 Owner: MR. MULLER Date of Inspection: 6/9/01 c D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to'each of the following for alLinspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private-water supply well. X 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. iThis 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 flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X 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 of 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. Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4027 MAIN ST CUMMAQUID,MA 02637 Owner: MR. MULLER Date of Inspection: 6/9/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. 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. n/a 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. ND explain: n/a 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 _ distribution box is leveled or replaced ND explain: n/a 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: n/a r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4027 MAIN ST CUMMAQUID, MA 02637 Owner: MR. MULLER Date of Inspection: 6/9/01 Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period ? X Have large volumes of water been introduced to the system recently or as part of this inspection ? '1 Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ 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 X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) C; " � C Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4027 MAIN ST CUMMAQUID,MA 02637 Owner: MR. MULLER Date of Inspection: 6/9/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval _ Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1998 Were sewage odors detected when arriving at the site(yes or no): NO A Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4027 MAIN ST CUMMAQUID,MA 02637 Owner: MR. MULLER Date of Inspection: 6/9/01 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction:_concrete_metal_fiberglass_polyethylene other(explain)PLASTIC If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H 5' 6" W 5' 8"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" 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: n/a 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE GREASE TRAP: _(locate on site plan) Depth below grade: n/a 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 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 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4027 MAIN ST CUMMAQUID,MA 02637 Owner: MR.MULLER Date of Inspection: 6/9/01 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 Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: _(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): THERE IS NO DISTRIBTUION BOX PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R f -Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4027 MAIN ST CUMMAQUID,MA 02637 Owner: MR. MULLER Date of Inspection: 6/9/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a 1 leaching fields, number: 8'X 16'X 2' n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY.THE FIELD SHOW NO SIGNS OF HYDRAULIC FAILURE. 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 or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a s 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 0 Flage 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4027 MAIN ST CUMMAQUID, MA 02637 Owner: MR. MULLER Date of Inspection: 6/9/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 2CODD ��as PA i5 9F a1 13C 3t z Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4027 MAIN ST CUMMAQUID,MA 02637 Owner: MR. MULLER Date of Inspection: 6/9/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 7 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED FROM A SEPTIC INSPECTION DONE IN 99-GROUNDWATER IS AT 7' 4' ` TOWN OF BARNSTABLE LOCATION 'tG Z-� �}" SEWAGE # j VILLAGE �1iy1A U I ASSESSOR'S MAP & LOT -O j INSTALLER'S NAME&PHONE NO. 2 SEPTIC TANK CAPACITY 0 13 LEACHING FACILITY: (type) 1.� (size) FX /� V2 NO. OF BEDROOMS BUILDER OR OWNER �' �'� I& PERMITDATE: COMPLIANCE DATE: jSeparation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility t ' FeiA 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) G',��- Feet Furnished by y , , , ! 1 �1 S ono TOWN OF BARNSTABLE .0LATION `1Q SEWAGE # i n '.�t.AGE C�� v/ ( nn ASSESSOR'S MAP& LOT `0 INSTALLER'S NAME&PHONE NO."�' 'SEPTIC TANK CAPACITY d e5, •LEACFENG FACILM: (hype) (size) F X Xz NO.OF'BEDROOMS Z / r� BUILDER OR OWNER l v v'�' . ke it 2 PERlvrrDATE: COMPLIANCE DATE _ Separation Distance Between the: Fe A Maximum Adjusted Groundwater Table to the'"Bottom of Leaching Facility �" _ Private Water Supply Well and Leaching Facility (If any wells exist . �r on site or within 200 feet of leaching facility) ° ` k eet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)" l'Feet Furnished by - Alt Sir. . �r Nk� t^r aq. �X3 ':' �.6 �= TOWN OF BARNSTABLE LOCATION `T Da / �,AD S-�• SEWAGE # `O VILILAGE �� tl ASSESSOR'S MAP & LOT •INSTALLER'S NAME&PHONE NO. -P- r, .ram SEPTIC TANK CAPACITY Ja' U 0 QX5&. LEACHING FACILITY: (type) �(eaC Nn 1--1 6 (size)2•Molar NO.OF BEDROOMS BMDER OR OWNER AV'00Q '-f:S%'N PERMIT DATE: COMPLIANCE DATE:_ I-�°Dlgq 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 mr within 300 feet of leaching facility) � — Feet Furnished by i V I ' d4 I No. r7 Fee 4 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z(pprication for Mi!5paaf *pgtem Cowaructfon Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Addr&ss0 a.-ott No / Own�GAQd�diess Tel. Assessor's Map/Parcel 3 3s — Q 3 0 Installers Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �s 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 °Z gallons per day. Calculated daily flow 2 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature f Repairs or Alteration (Answer when pplicab ) 41W1 5-� s -V r/L"//L/ I VXT( Date last inspected: ` Z �� s Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions qfTitN 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by t 's Boarjj�qf ealth. Signed Date Application Approved by Date p 1,6 —g'S° Application Disapproved for the ollowing reasons Permit No. q,-7-- 7 Date Issued Fee f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppfication for nigpogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Ad s0s or. -T Lot No ` n Own rg s�1aai_e� ress d Tel. Assessor's Map/Parcel '3 3 5 0 0 �(�( Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder,(` ) - Other Type of Building No. of Persons Showers( ) }Cafeteria( ) Other Fixtures _ y , Design Flow Y� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title --Size of Septic Tank Type of S.A.S. Description of,Soil / Nature of Repairs or Alteration (Answer when pplicab e) 1 Soo --/V '�,,rr'�� I r r C/ Date last inspected: .f'!r-1- Q Agreement: The undersigned.agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions gfTilde 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boarilof Health. - Signed Date 2 Y— Application Approved by ,. Date ;X _ ¢� Application Disapproved for the ollowing reasons r Permit No. 7 Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance T141S IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( kf )Upgraded( ) Abandoned( )by at (40 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permid ha11 of b e, ons trued as a guarantee that the system it f`uun`ction as degigned�` Date �.� � Inspector --------------------------------------- Fee 5 C, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS YMigpogal *pgtem Congtruction,Permit Permission is hereby granted to Construct( )Repair( Up pade( )Abandon( ) System located at 7 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 this permit. Date: Approved by r r. J B1=;RNSTABLE LA HD COURT it RT REGISTRY a lad 2 RESTRICTIVE COVENANTS William A. and Miriam L. Reilly hereby impose upon property at 4027 Main Street, Cummaquid, MA 02675, Barnstable County District Land Court Document No. 623449, the following I restriction: The single family dwelling and land known as ----- 4027 Main Street, Cummaquid, MA 02675 containing 25 acres, Barnstable County District of Land Court Document No. 62345 shall be no more than two (2) Bedrooms. Said restriction shall be binding upon the Owners, Heirs, 'J Successors and Assignees. EXECUTED this 24th`.Day of February, 1999 _ William A. Reilly Miriam L. Reill 1 Owner Owner COMMONWEALTH OF MASSACHUSETTS February 24, 1999 Then personally appeared the above-named William A. Reilly and Miriam L. Reilly, and acknowledged the foregoing instrument to be his and her free act and deed, before me ��i11e111N N 1 N��yr,; BARNSTABLE COUNTY REGISTRY OF DEEDS g�g_ Ckfjq�� A TRUE COPY,ATTEST Notar ubl. y �mmission Expires JOHN F.MEADE, EGISTER u SRY&N I QUIGUy,, Public MY Comrkis,gRn 14"nii September RARNSTAAI E REGISTRY OF DEEDS 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) 1, P , hereby certify that the application for disposal works co �ns ruction permit signed by me dated . LY C?c�cerning the w property located at 'L 0o meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will 114.t be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) .b B)Observed Groundwater Table Elevation(according to Health Division well map) E�- 0 .Lu s SIGNED : / DATE: LICENSED SEPTIC S TEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. - q:health folder:cert 1 .. Q� _ , .v, 1 r u o � A , i r t�M I t•.A P LV-S�.. E I VALERIE P. NEMMILA qhE: I 4019 MAIN ST. C'UMMAQUID , MA. �'�� E t� SK . 7167 PG . -72 OT i PL 5K c�'0 Pv .76 'a JAN � E BARBER � 1 248 STEVENS ST, O r� HYAI ti i S , MA. 02601 6K . 2419 PG. 149PLOW �. Dirc -411 S6•T f`•J � ' 1 P F( s �♦ 1 cl � , e; 1 �T, /all kb toy L,)T d C f y V► t\; -= 8K 3363 W `'ARY ;n I vU