HomeMy WebLinkAbout4061 MAIN ST./RTE 6A(BARN.) - Health 4061, MAIN STREET RT6A, CUMMAQUID
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TOWN OF BARNS�TABLE
LOCATION SEWAGE#
VILLAGE��,-,nsw6C. ASSESSOR'S MAP&PARCEL <'
IFS NAME&PHONE NO-
SEPTIC TANK CAPACITY \O�p�.®(S" - 65
LEACHING FACILITY:(type) Scams G,c.` ��,,�.,�,�,-cf'r, (size) 3-
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 7 Sr 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
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Commonwealth of Massachusetts COPY
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaguid) MA 02630 Februa rr7 2013_
every 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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick T. Sullivan
cursor-do not Name of Inspector
use the return
key. Ready Rooter Excavating
Company Name
P.O. Box 89
Company Address
Forestdale _ MA 02644
City/Town State Zip Code
508-888-6055 SI 12843
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
February 15, 2013-- ------------
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.
Zoe
t5ins•11/10 Title 5 Official s lion Form:Subsurface Sewage Disposal System•Page 1 of 1
Commonwealth of Massachusetts
PA
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaquid MA 02630 February 7, 2013
_ _
every page. City/Town 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:
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 29'"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 pas�'inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that e tank is less than 20 years old is available.
❑ Y ❑ N �` ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage ISYstem•Page 2of2
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaguid) _MA 02630 February 7, 2013
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break ut or high static water level in the distribution box due
to broken or obstructed pipe(s) or duet a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Bo rd of Health):
i
❑ broken pipe(s) are replaq)6d ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is remov ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is eveled 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):
i
C) Further Evaluation is Req/fired 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 pf otect public health, safety or the environment.
1. System will pass nless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that th system is not functioning in a manner which will protect public health,
safety and the en ronment:
❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 4061 Main Street (Route 6A)
Property Address
Jean Kroeber _
Owner Owner's Name
information is required for Barnstable (Cummaquid) MA 02630 February 7, 2013
every 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 �S and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS aid 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 jwaranalysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absenhe presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided tother failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® 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 '/z day flow
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street(Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaquid) MA 02630 February 7, 2013
-
every page. CityfTown 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 hin 400 feet of a surface drinking water supply
❑ ❑ the system i within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the syste is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— PA) 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 Sect' n D above the large system has failed. The owner or operator of any large
system considered a Sig ificant threat under Section E or failed under Section D shall upgrade the
system in accordance w th 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber _
Owner Owner's Name
information is required for Barnstable (Cummaquid) MA 02630 February 7, 2013
every page. City/Town 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaquid) MA 02630 February 7, 2013
_
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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 years usage (gpd)): 2011= 68 GPD
2012= 79 GPD
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Fall 2012
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day igpdi
Basis of design flow (seats/persons/sq. ., etc.): _
Grease trap present? `/ ❑ Yes ❑ No
Industrial waste holding tank pre 4nt? ❑ Yes ❑ ,No
Non-sanitary waste discharge�to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if avLable:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaquid) MA 02630 February 7, 2013
_
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
No records found
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaquid) MA 02630 February 7, 2013
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:
Tank over 25 years old. D-box and SAS added 11/18/1998. Certificate of Compliance on file at Health
Department.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2 6
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. N/Afeet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
1'8"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
M Dimensions: 8.5' X 4.5' X 4.5' 1000 gallons
----
Sludge depth: 4rr--
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber _
Owner Owner's Name
information is Barnstable (Cummaquid) MA 02630 February 7, 2013
required for
every page. City/Town 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
31"
0.1
Scum thickness —
6-1
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 14"--
How were dimensions determined? Tape measure and dip tube.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet PVC tees in place. Liquid level at outlet invert. Old outlet tee still in p�ace but 1"above
newer outlet tee. Risers bring covers within 6"of grade. Recommend maintenance pumping every 2-
3 years. — --- — — - ---
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scu /pof et tee or baffleDistance from bottom of of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is Barnstable (Cummaquid) MA 02630 February 7, 2013
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: —
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: — Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official l;nspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaquid) MA 02630 February 7, 2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
One inlet, two outlets to SAS and one outlet for vent. Equal flow to SAS. No sign of high water
staining over outlet inverts. D-box is 6'6" below grade.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cumma uid) MA 02630 February 7, 2013
every page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number: —
® leaching chambers number: 3- 500 gal ea w/4' of stone.
❑ 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.):
Camera used from d-box to locate and inspect chambers. Dry at time of inspection. No sign of past
hydraulic failure. High water staining 3"+- above base of unit.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer -
Dimensions of cesspool --
Materials of construction --
Indication of groundwa er inflow ❑ Yes ❑ No
t5ins-I V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is Barnstable (Cummaguid MA 02630 February 7, 2013
required for _
every 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: — —
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ,f
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street(Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaquid) MA 02630 February 7, 2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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
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t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaquid) MA 02630 February 7, 2013
_
every 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: >5
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. 1998
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:
ma.water.usgs.gov terraserver-usa.com _
You must describe how you established the high ground water elevation:
Test hole info from 1998 shows adjusted ground water at elv= 20. Base of SAS at elv=41+-.
Accessed local ground water contours and topo mapping. No high ground water in area of system.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4061 Main Street (Route 6A)
Property Address
Jean Kroeber
Owner Owner's Name
information is required for Barnstable (Cummaguid) MA 02630 February 7, 2013
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE
L . YbN ® e O y re 4 A SEWAGE # 9� 70 J
14 LAGE C Utit M A 0 V la" ASSESSOR'S MAP&LOT 3�r
INSTALLER'S NAME&PHONE NO. -/1-1, Ad A C 0 Nl 19 ell S' aN
SEPTIC TANK CAPACITY A®D,0
LEACHING FACILITY: (type) 3-AL6 C A7 Nl/I, elf (size)
NO.OF BEDROOMS ✓�
BUILDER OR OWNER
PERMTTDATE: 7 A�I COMPLIANCE. DATE: A
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
_____
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE& MASSACHUSETTS
2pplication for Mfgpogar *pgtem Congtruction permit
Application for a Permit to Construct( )Repair(KX)gUpgrade( )Abandon( ) ❑Complete System O Individual Components
Location Addressor Lot No.4 0 61 R t e 6 A C umma qu i d Owner's Name,Address and Tel.No.
Kroeber Tony 3 E, 0 A9A'iass.02637
Assessor's Map/Parcel C3�
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass.02632
Type of Building:
DwellingXXXNo.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 440 gallons per day. Calculated daily flow 3 x 1 1 0 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 Alterations(Answer when applicable)
Adding three five hundred gallon chamhPrs par-kpd in 4 ' of 1^1," Sf:0A.c_
All impervious solis will be removed for 51 all aro unci and unr9er the
leaching chambers.
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 b this 4oW of Health.
Signed i Date 1 1 /2/9 8
Application Approved by Date --
Application Disapproved for the ollowing reasons
Permit No. Date Issued
.mil'uts.` va` `_�`• _ _ �.+'E `�
No. -. ;+ ,'j "-.. Fee $ 5 0:0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
- _ :..._..,�.��....�•— � Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS-
01ppricatfon for Di!5po5af *vmem Congtructton Permit
Application for a Permit to Construct( )RepairNX�tUpgrade( . )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot NoA 0 61 Rte 6 A Cummaquid Owner's Name,Address and Tel.No.
Kroeber Tony ass.02637
Assessor's Map/Parcel !rt �:
Installer's Name,Address,and Tel.No. 5 00 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No.5 0 8—7 7 5—3 3 3 8 '
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass.02632
Type of Building: r
DwellingXXXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 4 4 0 gallons per day. Calculated daily flow 3 x 1 1 0 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 Alterations(Answer when applicable)
Adding theee five hundred gallon chambers packed in 4 ' of 1-1" st•obe
All impervious molis will be removed for 5 ' all around and under the
leaching chambers.
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 )a4d of Health. _
Signed r Date 1 1 /2/C9L8
Application Approved by Date 11- 3—
Application Disapproved for the ollowing reasons
Permit No. r !e) Date Issued A
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( paired (XX)Upgraded( )
Abandoned( )by J.P.Macomber & Son Inc.
at 4061 Route 6A Cummaquid,MASS. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
InstallerJ.P.Macomber & Son Inc Designer J.P.Maco be Son-Inc,
The issuance of this permit shall not be construed as a guarantee that the syst 11 '11 fun ion as,d$signed.
Date Inspector
————————— --------=—= ------
No. Fee $ 50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migogar *paem Construction Permit
Permission is hereby granted to Construct( )Repair(XX)Upgrade( )Abandon( )
System located at 4061 Route 6A Cummaquid,Mass.
� I
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.
L�4
Provided: Construction must be completed within three years of the date of this permit.,,#.-
Date: It— — ?7 Approved by . �
r
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, Joseph P.Macomber_,7r. , hereby certify that the application for disposal works
construction permit signed by me dated 11 /2/9 8 , conceming the
property located at 4061 Route 6A rumma?ui d, Mass; 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 now 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 a91 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) Q
B) Observed Groundwater Table Elevation (according to Health Division well map) /
SIGNEDrDSEPTIC.
�� DATE: 11 /2/9 8
LICEN SYSTEM 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).
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TOWN OF BARNSTABLE.
LOCATION 9 O U 7 e (o A SEWAGE# 94F- 7 O J I
VILLAGE C Ulm Al A Q v I d" ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. A C 0 /9 eX t S oN
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) -?-)'�'L 6 41 cH A A! et (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMPTDATE: 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
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11:0- T 10y ���''� ` SEWAGE . PERMIT NO.
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VILLAGE
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I N S T A LLER'S N A Mf A ADDRESS
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B U I L D E R OR OWNER
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DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED I`
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
------i 0 ............OF.... ....... � 'T/ , ,, .......... ....
Allp iratiun for Diupuuttl Works Tunutrurtiun Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( P<an Individual Sewage Disposal
System at•
..... - .................................
Locatio Add or//p or Lot-No.
4�.......LL.LN z................................ . ...............................................----..............................................
W ne ""� Address
F'�2 ...... �d4� •--•---•-•-----••---•-----------------•-------. .....-•---...................-----.....--•----
Installer Address j.
UType of Building Size Lot............................Sq. feet
Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers
a —Type g ---------------------------- p ( ) — Cafeteria ( )
dOther fixtures . ---------------•---•----•-•-•--•------•--..-.-..----- ------------
W Design Flow............................................gallons per person per day. Total daily flow........................._..................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.............--- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.........---........ Depth below inlet.................... Total leaching area..................sq. ft. t
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-•--------•------•--••-•••••-......----•••-••-------•--.........•---•--_. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.---....................
a ......................... ---•-•-••..............•--•--•---••-------...•-----•-----...------....-_-•--------------.......--••-••-•---••---•-•----....-•-...•.
ODescription of Soil.........................................................:...............................................................................................................
W
x -- ------------------------•--
U Nature of Repairs or Alterations—Answer when applicable... "/Q�'J -�- //�....................•--•-----•-_•-•-_....---.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of r'ITL% 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by e b and of health.
' Signed L .... .... .._.
Date
ApplicationApproved By--•------ ... ..... •-• ._.........•.. .................................... ........................................
Date
Application Disapproved for the f 7 ing reasons---------------------•------•----------------.......--------...--------...------••---------...--•--•-••---......
------------------------•--...-----------•---•--•----------•---------•-••-------•---------••------...-----••-------•-•.........--••----••---•-•-...--••-••-----•-••-••-•-•••-•••--•-•--••-•-•---•-.-----
Date
PermitNo......................................................... Issued........................................................
Date
No................_....... Fss ............ 1�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
. Z'
Apphrafiurt for Kiapusal lVarkii Tonsfrurtion Frrntif
Application is hereby made for a Permit to Construct ( ) or Repair ( 0an Individual Sewage Disposal
Syst/em,`at: [_
•--. .�?lf/. _}i F.d ..:.r rC�.... &'.11ttr._a!# r��, .. ........ ......•....... .........---...............„.............._....
_ Loc....at',o -Add or Lot No.
w
.. ,caner /' ...... .. Address .....................__......_........
Installer Address
UType of Building Size Lot............................Sq. feet
�-� Dwelling o. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures .
w Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Dept h................
x Disposal Trench=No..................... Width.................... Total L6ngth.................... Total leaching area...................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank--( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P •----------•------------------------•-----------.........---•------•--•-•---•----------...-------•--....................................................
0 Description of Soil................................................................... .......-........-...........-------------------------------------------..........*.................
x
c, •-•••-•--•-----•-------------•.........._.............--••-•--•----•------•--.....-•------•-•...........--•-••-----•---- ....-----•---...
w
UNature of Repairs or Alterations—Answer when applicable.... .........
............................................................................................................l...M.aI%A/d .:-...1..._ ....................................................
Agreement: .
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until.a Certificate of Compliance has been issued by the board of health
Signed cry t :> � " %` �'`n'f!r1••f - f' ... ...
at '
Application Approved By-----••----•.... ............ ............-- ------...........--------.•....... ....................Da.-e...............
Date
Application Disapproved for the f o.o_ 'ng reasons:--•---------•..................•-------------------------------------------•..........................-----
.........................._............................................................._.........................................._.............................................................___
" Date
PermitNo...................................................._.... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(Inftf i.ratr of Bunt phitnrr
THIS 1- TO CERTIFY,/That the Individual Sewage Disyosal System constructed ( ) or Repaired (440�1
by.......V"_.._SL�4!e r f ........Z. ems: s :FZ> :• ..................... ............... ..
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d�� rnstallerX(E / -
hasgeen installed in accordance with the provisions of TITLE 5 of The ;ItSanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU)NCTION SATISFACTORY.
DATE.................. .114'a C Inspector....7 ...................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No....... ....,,? r��✓t-�.��..........0F.....l�i ✓ c.> ��!la/ ........................ _
Fn....e.J:..�J..��..
�i��uu�i urk� ��rn� � tttfiun .rrnti�
Permission is hereby granted....✓.../' � »g ....•---. ..
..e . ........................ ___
...._
to Construct ( ) or Rep ' (�an In A ual S .wage isposal System
at No........ r�l /-•--.... - = ...�.:f.. : ..... .............
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..... ..,.+.�..`..}�.(�.........
-� T a d of Health
DATE ' .. ..�Ea.... ....,
FORM 1255 A. M. SULKIN, INC., BOSTON