HomeMy WebLinkAbout4310 MAIN ST./RTE 6A(BARN.) - Health rj e Main St.reetJRte 6A (Barnl
" Barnstable P
A - 351 030
a a t
{
rtP
1
Q
r
3,5/- 030 Q '
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`M 4310 Main st w
Property Address
Don and Linda Alhart
Owner Owner's Name -•7
information is required for every Barnstable Ma 02630 1/27/17
page. Cityrrown State Zip Code Date of Inspection rV
' 4Jt
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out formson the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
Company Name
8 Johns path
Company Address
S Yarmouth Ma 02664
City/Town State Zip Code
508-364-9587 S103522
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
2/1/17
nspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4�M 4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is, Barnstable Ma 02630 1/27/17
required for 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:
System is in good working order with no si ns of failure
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
i
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass_ with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N, ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M °y 4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
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
El ® 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 '/day flow.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4310 Main st
M
Property Address
Don and Linda Alhart
Owner Owner's Name
information is Barnstable Ma 02630 1/27/17
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
f.hr system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is.a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
F
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
<ca
4310 Main st
M
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
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): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is Barnstable Ma 02630 1/27/17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 218 Gpd
9 ( Y 9 (gp ))� I
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
I
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15."203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
page. Cityrrown 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: None provided
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Ili
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
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:
Unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
• l
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
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
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No evidence of Ieaking,Tees and or baffles in place at time of inspection.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
4310 Main st
M
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
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.):
Tees are in place and levels are normal.
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 El polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Level and at normal level
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
6'x10'
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No signs of failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts =-
W Title 5 Official ,Inspection Form w
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4310 Main st
Property Address
Don and Linda Alhart'
Owner Owner's Name
information is
required for every Barnstable Ma 02630 1/27/17
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.):
No ponding no break out
• r
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.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
fi�">#r y rs•� ��n� �P ���ra Py��� r
r k n :<-r ,«•, vt-- ;of�MaSs�r.su r r� A
oriweaith��
v � aC.}�1��Q, a`�v�3P�1 i" _qd •L 4 ,�` •€ ,^>� #}3T 1}` , ��, a.�. � .t.�a.&,�'
E sW✓ ,q,€ k F.E ).. NJ �,v..• i !It / ; 'EJ $E.l. * ^g, tk 'Ya
,�r�.�,a � i �.. � 6JG���F';� :�E �'•� >a ■ Yw�t`r.r r m.F €�, -• 1�€ ,,' $nj ,=�j�b c : 't •E xy '� �y-�,.
t ! f '�'��/�� x,e. ,,iv e, #i-•,��� �law
�shd�� '•�� e � `�x� s�.� ` ".�'�` � .� .E�_. .� �i � �� EE'���� aa
r ,,v I! ,�'�� �f „ ;:.E 4�,v,kr sy,xv '#-' :to Y" � t � .:Z: F�.. ;.k ._�`£� 3 ! �• � 5' � 5
`Y S�BZ
WOOD
�' >•i roa
4 ` a'�ip,'',�, �t"F�.� ,,
r ett A' ASS, i dF# dti €!w a Y h y b ' 5
OWN—
,ay, ryas#.u���., s
rr� l*1JZt° .� "€'rY' -:11 bias€au
y
�K AA
PhH
yi1 8 YAn_IS:. r �z'l �n C;. t Phu r rj ai.Equ wu ainl�€ r nN tr a'-Y :L:�a:-�'�IM
1.i
V: tynOWn=
.,pag�r9 r �E� J EFL� }.,%. � i •E',y 4�� rn �'. � '* �€>,,�#£ �5y ,s� '�'P,�"' 1"i �`?�� � �Ar� �
..
tat .. %.c
r �:T.-.ip
h " E �' lni�iPi'n�}7R�`i' 1 •kRE S P.G�JO
€ �4 Pti ^ih7^''1a• r '� �.v: C2i r�
EE ° E nE
''r` e„
v ;;sr �x�` 'xr as {€`'�' r'e•.. PJtC S y., s
N aEno "'.LAM , , � ` E�`. �"`' € E Z
all
y��,�r`EEr•,�(r,� '§� " � S:h.V � � �J�y;y��� �� fi �•�i 7 t ' � a�` ,€ �c �
r` r+tt K, s 1`i h -' +• ` _ f
a
. i vt € ., ga ��sPosalS
�,e�{; F'rov►efe.' E',§� ��,�(;.-.,�'..t t �� �L � ��`�' a Y- �g
., sAt.!e ,t two erm w a sketch ..
P n ,.. of`tE a sewa a tiffs osal s, stem-�ncWin
� Y,
S## 9 :
�a.:�y�,��, � r�� ere ,u�{ f.� �� ,���, ,chmarks.Locate ail w I ,' •> � !
a '°a aver supp € me f E
bKM
ui�d�n(y
a
E
� /� .•�q�, � ,r x f s:: e LE a S� a a - � sz?'v��,�+ � _.r a a
_ j ^a �'i ha-�, 'ar��_ �r_,�^� E E,r�.'§��€ �,����'��� -. € t`�,# •�,� E Y � i.. � ; � r ° "�€,.,�g"'
r '
' � y �, z�� ,#t�'?€fl ,uk•�i'`�» � ,t' �$ ry,. F gE.: r1��:: Ei. 4 �lur
"'iE1, `k F 6 d i ,•,E : A Ear € 3 'i viy€ k«• tE r° 1 ` A `:. 0t
rs��� '� - r 2� ,J�'P r D� g�� as9E� � £ E T : E�' � '.� •>�
-j pr�k A a a�r:�• a .;��Ssw`°ti"` '� �a X`C'i�€.#>�: t a - R., it
�E h
�' '•-5 'L v r., tf, .n,_.� r � a7� ,� � � � EP J 'C� :;€¢� ,stF � �t� ;'„''
, t. E ELF R` � ��'�c iz ,��•�� 3- �� �
v1'�#-"�, t �i'1n.��,�i"�,Y�r�yy��i€� �tw•�tE=„ � Ord.3� � X as �•�.4gw'�rs �,� � _ < ems' .�I�»� r�� �t «•',
"� r,L .g'uY,��3 �i1t �i� ":-��z'irs�� �r sn�Ev `� � � ��' � o�F• a ��- ��'#
r i F; f`.�b 1 i a �n €�� �'.n i # f:, E� �� t E �. # 3 F� ��a � •�+ # - ��,
''�- ,,. �s i•,• e� � i{gtii �e' E-9i 4., .r �,,:.. IEa.,vE>1.,,,i �i�3 - j#� �f 2 �\.<. �.E`?_ y-�: g$ �.:x�
J'l p E ti'• i r3��5��E' � 'g",1,Y 553� # �q `� e,
�r N°f �P'�'��` .�� `•� ri :t�J��#�'' _,&��,{�Sr '>~�y`"•+ m.€' ,���s >`H� �'x�A Cw+„ � 7� , €�7 ,"y :v a.
J 'r. 'sr ( i� !y�.,,' ,,t ,��,��„�, f aG.€�aa��"�t�!�a i"� "•3",�E'�i'M
r
x, r � xf° � ! �r ELF ..r .�✓,�' � Y1 `'?'rh` `� Q{ r `�� s_ ,aa- .; ?�
i
f
6 3
T r
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
_ o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
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: 10+ ft
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting 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:
Test hole data at 4308 indicates NGE at 10' FT
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
_ Commonwealth of Massachusetts
AME. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 4310 Main st
Property Address
Don and Linda Alhart
Owner Owner's Name
information is required for every Barnstable Ma 02630 1/27/17
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4310 Route 6A, Cummaguid,Ma.
Property Address
Whitney P.Wright
Owner Owner's Name
information is
required for RnrnStah1 P Ma. 02630 3/27/07
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.
Important:When filling out A. General Information
forms on the J
computer,-use 1. Inspector:
only the tab key
to move your Douglas A.Br own
cursor-do not Name of Inspector
use the return
key.
Company Name
P. O.Box 145
Company Address
Centerville Ma.. 02632
City/Town State Zip Code
508-420-7159
Telephone Number License Number
I
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 1"5:340:of
Title 5 (310 CMR 15.000). The system: I
r
E] Passes ❑ Conditionally Passes. ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority.
L—Inspec s i " ture Date
The sy tem 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
t 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.
t5lnsp.doc•08/O6
Title 5 Official Inspection Ponrr Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
--I Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
�M � —-----�,:3�-O--B.a�t e--E}!�-,-G�z m_m a�-w -d,-�Ia=�---------------------------------------------------------
Property Address
---Whitney P.Wriaht- ------f----
Owner Owner sName --------- ----- ----- -------- ---
requiratifor Barnstable Ma.
required for _ --..._._..._. 02E?30
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:
�j 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 is in very good condition,and shows
no---e-vidence -o-f..-s-o13-cis -ca-rry. .ove-r -i-n--the:. S.,A,S .. .._._ ._ -- -
13) System GeRdifie"lly Passes-
❑ One or more system components as described in the"Conditional Pass"section need to
replaced or repaired. The system, upon completion of the replacement or repair, as a oved by
the Board of Health, will pass.
Answer yes, no or not determined(Y, N, NO) in the ❑for the following stateme . If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old'or the septic tank ether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltrati or tank failure is imminent.
System will pass inspection if the existing tank is replaced h a complying septic tank as
approved by the Board of Health.
A metal septic tank will pass inspection if it is ucturally sound, not leaking and if a Certificate
of Compliance indicating that the tank is le an 20 years old is available.
NO Explain: �
❑ Observatio sewage backup or break out or high static water level in the distribution box due
to broke r obstructed pipe(s) or due to a broken, settled or uneven distribution.box. System will
pass spection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
t5insp.0oc•o1lfo6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
r
t y
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4310 Route 6A,1uquidMa.
Property Address
Whitney P.Wright
Owner Owner's Name
information is Barnstable Ma. 02630 3/27/07
required for
every page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken o obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipes)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by th oard of Health:
❑ Conditions exist which require furth evaluation by the Board of Health in order to determine if
the system is failing to protect pu c health, safety or the environment.
1. 'System will pass unless oard of Health determines in accordance with 310 CMR
151303(1)(b)that the syst is not functioning in a manner which will protect public health,
safety and the environ ent:
❑ Cesspool privy is within 50 feet of a surface water
❑ Cess of or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. Syst will fail unless the Board of Health(and Public Water Supplier, if any)
sete nes that the system is functioning in a manner that protects the public health,
af 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
Mplily WWII.
t5insp.doc-08106 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 4310 Route 6A, aumm-a.0Aid,Ma-
Property Address
Whi tt,nP Wright,
Owner Owner'" s Name
information is
required for RarnstahlP Ma Q263n 3/27/n7
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fee
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, pert ed at a DEP certified laboratory, for coliform
bacteria indicates absent and the pres nce of a onia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no o e it 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 Y2 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 groundwater elevation.
O Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp.doc•08/06
Title 5 Official Inspection Forth: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
N PropertyAddressf�tP 6A rummauid,.Mn:�
_Whitney P.Wright
Owner Owner's Name
information is Ma.
required for Barnstable 02630 . 3/27/07
every 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 5.0 feet of a private water supply
well.
❑ U 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.]
❑ E The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ Et 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.
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 ition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 fee of u e drinking water supply
❑ ❑ the system is within 200 of a tributary to a surface drinking water supply
❑ ❑ the system is to d in a nitrogen sensitive area (Interim Wellhead Protection
Area—I or a mapped Zone II of a public water supply well
If you have answered" to any question in Section E the system is considered a significant threat,
or answered"yes" ection D above the large system has failed. The owner or operator of any large
system con . red a significant threat under Section E or failed under Section D shall upgrade the
syste i accordance with 310 CMR 15.304. The system owner should contact the appropriate
r nal office of the Department.
t5insp.doc•0=6
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
o
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131.0 Route 6A , .»mma uid ,Mn _
Property Address
Whitney Wright
Owner Owner's Name
information is
required for Rarnstah1 M2 o263o 3 /27�/g7
every page. City/Town State Zip Date of Inspec Code tion
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
❑ [0 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?
including
❑ 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?
FXI ❑ 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)]
t5insp.doc•08/06 Title 5 Official In
spection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5•°'� 4310 Route 6A,.e_U_A'2 4 AM U/Z3 � �10 .
Property Address
Whitney P.Wright
Owner Owners Name
information is
required for Barnstable M—�?_ 02630 3/27/07
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): — 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 GPD
0
Number of current residents:
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)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 2003
Date
Type of Es ishment:
Design flow(based on 0 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/perso qA., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ .No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4310 Route 6A, Cumm,aqu d 9 Ma:
Property Address
Whitney P Wright
Owner Owner's Name
information is
required for Barnstable Ma. 02630 /27/07
every page.. City/Town State Zip Code Dafe.of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
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:
FLI 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)
El Tight tank.Attach a copy of the DEP approval.
El Other(describe):
Approximate age of all components,date installed(if known)and source of information:
11 /25/87 permit #87-781
Were sewage odors detected when arriving at the site? ❑ Yes a No
t5insp.doc•08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
— 4 310 Polite h 004M gq&D,Ma..
Property Address
Whitney P. Wright
Owner Owner's Name
information is required for Barns table ,Ma. _Mq-` 2630 3127107
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Building Sewer(locate on site plan):
1 Depth below grade: feet �rr
Material of construction:
lj] cast iron [ 40 PVC ❑other(explain):
Distance from private water supply well or suction line: Plus
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
May be some leakage at jointin two piece tank,-house- bas,
not been occupied since 2003 ,and liquid levels in tank are
Septic Tank(locate on site plan): below outlets
10"- 24ft
Depth below grade: feet
Material of construction:
concrete IQ metal Eaflberglass JU polyethylene ❑ other(explain)
If tank is metal, list age: NAyears
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1 ► n X, f R f►X, t 7 n H
Sludge depth: .
6n
Distance from top of sludge to bottom of outlet tee or baffle
2 ' 3"
Scum thickness 0
0
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? measured
t5insp.doc•08/06 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4310 Route 6A,(,umftaiqui.d,Ma.
Property Address
Whitney P.Wright
Owner Owner's Name
information is 02649
required for Barnstable Ma. 3/27/07
every 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.):
inlet tee 'Is }outlet baffle and tank appear to be in good
condition.Dwelling has been empty since 2003 liquid level
in tank shows some leakage in the . two section tank.
Grease Tr
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene other(explain):
Dimensions:
Scum thickness
Distance from top of scum to t/and
or baffle
Distance from bottom of scumtlet t or baffle
Date of last pumping: DateComments(on pumping recolet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlece of leakage, etc.):
/below
k(tank must be pumped at time of inspection) (locate on site plan):
n:
❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
t5insp.doc-08M Title 5 Official Inspection Form:Subsurface Sewage spectl g Disposal System•Page 10 of 15
i
Commonwealth of Massachusetts
_ Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y 4310 Route 6A,-Qummaquid;)%.
Property Address
Whitney Wright
Owner Owner's Name
information is
required for Barnstable , 02630 3/27/C17
every page. City/Town to a Zip Code Date of Inspection
D. System Information (cont.)
Tight or HeldiRg Tank (eeRt.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Y ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of ala and float switches, etc.):
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any.
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
o
t5insp.doc•08/06 Title 5 Official inspection Form;Subsurface Sewage Disposal System•Page 11 of 15
• J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`y ___4 310 Route 6A , Gumna.giuid,_Ma
Property Address
_Whi tnay Wright
Owner Owner's Name �-
information is 02630 3/2 7/0 7
required for Baxnsiab�e Ma•
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (coat.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NSA
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
f] leaching pits number: LY
r
leaching chambers number:
leaching galleries number
leaching trenches number, length:
leaching fields number, dimensions:
overflow cesspool number:
innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of.hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit 6X101 is 61 .deep with risers and steel cover at gr
grade . No indication of hydralic failure ,or solid carryover.
Pit was built in a 2 r diameter strip out01 deep to c ieart
sand.Per installers plan and inspectiot report dated
10/17/03
t5insp.doc•08/06 Title 5 Official n Farm:Subsurface Sewa
ge age Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4310 Route 6A, Cumrrg,_q-uid,Ma.
Property Address
Whitney Wright
Owner Owners Name
information is 3/2 7/07
required for BarnSta"hl P m_ 02h30
every page. Citylfown State Zip Code- Date of Inspection
D. System Information (cont.)
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction .
Indication of groundwater inflow ElYes ❑ No
hydraulic
Comments(note condition of soil, signs of hyding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of constructio .
Dimensions
Depth of so' s
Comm s(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
t5insp.doc•08M Title 5 Official Inspedw Farm:Subsurface Sewage Disposel System•Page 13 of 15
r
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
PropertyA reu-te-6A,Cummaquid,Ma
Whitney Wright
Owner Owners Name
information is
required for Barnstable Ma. 02630 3/27/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
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.
kl
e A
SToN E
f R'Tt D
N 126
/A
A A Z a-A, 45-3
A-13 141. a �r B-'8 3riL it
'-0��
1 0 �
t5insp.doc•08106 Title 5 Official Inspection Fofm:Subsurface Sewage Disposal System•Page 14 of 15
L)
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 4310 Route 6A,Cummaquid,Ma.
Property Address
Owner -Aitnek, Wright
Owner's Name
information is Barnstable Ma.
required for 02630 3/27/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
[] Surface water
® Check cellar
❑ Shallow wells
18-19r
Estimated depth to ground water. feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
Q1 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:
Abutting observatiQn hole& Usgs data base
You must describe how you established the high ground water elevation:
A8 p TT i*L G- Oa S E R Y A i t b N 1-1 o LE Kok
Ahlan USC-S 7 7;;4iA RASA
15insp.doc•08/06
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 15
DIITE:,_6/1.1 /98
PROPERTY ADDRESS: 430--Route 6A r
D
Cummaquid,Mass. 02637 . rs
0 199 _ .
On the above date, I Inspected the septic system at the above address. N
This system consists of the following:
1 . 1 -15Q0 gallon septic tank. '
2 . 1 -Distribution box.
3 . 1 -6 'x10 ' leaching pit packed in stone.
Bused on my Insoection, I certify the following conditions:
4 . This^is a title five septic system: � �( -78 . Code ' )
5 . The septic system is . in proper working order
'at the. present time.
.6-. The system was installed with a 26 ' foot dig out
and. clean sand brought in to the depth -of 22 '
7 . .The' cottage was not inspected at this time.-
SIGNATURE: '
Name: J . P.Macomber Jr...
Company:_ . P_Maco►gber & Son-
-- ----------- - ---- ;
Address:_-B,,.,_6i______I___,-_
Centerville Aass__0.2.632 ` t.
Phone:___,50.8.•Z75-3338------- - 1
t
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON,. INC.
Tanks-Ceupoola-Leachflelds
. Pumped 4 Instslled
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
77.5-3338 775-6412
r
' Dill
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617.292.5500
WILLIAM F.WELD TRUDY COX
Governor Sccrctw
ARGEO PAUL CELLUCCI DAVID B.STRUH
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions
PART A
CERTIFICATION
Property Address: 4310 Route6A Cummaquid,Mass. Address of Owner:
Date of Inspection: 6/11 /9 8 (If different)
Name of Inspector: Joseph P.MRcomber Jr.
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:J.P.Macomber & Son Inc.
Mailing Address: BOX 66 Centerville,Mass. 02632
Telephone Number: 508-775—" 118
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
,Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: F z- r Date:
The System Inspect all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
81 SYSTEM CONDITIONALLY PASSES:
4,0 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes,�no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:uwww.magnet.state.ma.us/dep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4 3)0 Route 6A Cummaquid,Mass.
Owner: Nancy Hopkins
Date of Inspectionr6/11 /9 8
e) SYSTEM CONDITIONALLY PASSES (continued)
&9 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
11)n_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
AQ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
�p The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
Qjp The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
�p7 The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance AO (approximation not valid).
3) OTHER
,L14
N
(revised 04/25/97) Page 2 of 10
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4310 Route 6a Cummaquid,Mass.
Owner: Nancy Hopkins
Date of Inspection: 6/1 1 /9 8
D) SYSTEM FAILS:
You must indicate ei;t.er "Yes" or "No" as to each of the following:
_/t/2)_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cornea
the failure.
Yes No ,
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distrib�u�tion box above outlet invert due to an overloaded or clogged SAS or cesspool.
— YCT
Liquid depth in-G"&pMI is'less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipeW.
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
41 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
IA-
AT- 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/)7) Page 3 o1 10
1�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 4310 Route 6A Cummaquid,Mass.
Owner: Nancy Hopkins
Date of Inspection: 6/1 1 /9 8
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No i
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
-Y-
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
X _ All system components, 'Xluding the Soil Absorption System, have been located on the site.
J _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions,"depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.N.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) ?ay• 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propersy Address:431 0 Route 6A Cummaquid,Mass.
0"ner: Nancy Hopkins
Date of Inspection: 6/1 1 /98
FLOW CONDITIONS
RESIDENTIAL:
Design flo". .p.0./bedroom (or S.A.S.
Number of bedr00ms:
Number of current residents:
Carbage grinder ryes or no). _
Laundry connected to system (yes or no).*
Seasonal use (yes or no)X/D ��CC/�p 191 �Gt� �0►')S �)� /lJ.
V.ater meter readings, if available (last two (2) year usage (gpd): / 5 1 ] /07, DOO Cj Q 16 s � fs u-,P D
Sump Pump (yes or no):w —�—
Last date of occupanc)-k-MW
COMM ERCIAUINDUSTRIAL:
Type of establishment:_
Design flow: Vo# 8allons/day
Crease trap present. (yes or no)A&
industrial \Waste molding Tank present: (yes or no)Z—014
.Non-sanitary waste discharged to the Title 5 system. (yes or no)it!/�
Water meter readings, if availa le.__�jt
Las, date of occupancy.
OTHER: ;Describe)
Last date of occupancy.
CENERAL INFORMATION
PUMPINC RECORDS and source of information:
System pumped as pan of ins ion: (yes or no)"
if yes, volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
Sepuc tank/distribulion box/soil absorption system
__,626 5ingle cesspool
VQ Overflow cesspool
Privy
Ahl Shared system (yes or no) (if yes, anach previous inspection records, if any)
UA Technology etc. Copy of up to date contraaf
Other
APPR (MATE ACE of all components, date installed (if known) and ource of information: ?�y �� /•�L
M� 12r f Sw
Se"age odors detected when arriving at the site: (yes or no) _
(T-vIsod 0 V 75/17) Page 5 of 10
J
`yo Lf
t\K 1 ��
1 �
ASSESSORS W no. 1 . , ..THE:COMMONWEALTH OF MASSACHUSETTS
PARCEL NO. D15b BOARD OF HEALTH
0........................op................Barnstable
........ ................................................................... 2 0 0 0
%ipaaal Workii Tnmtrn.rtivit rrrmit
Permission is hereby granted......,I...P._Mar-nmbex..............................................................................................___..
to Construct ( ) or Repair �XXX an Individual Sewage Disposal System
at No....A3.0.8...Rt.e.,....6.;4..Cummaquid ... -.._.._. Kent
.... ............... .................................... .............••---•--••---........
Street
as shown on the ap lication for Disposal Works Construction Permit No�.f.4�'�.! Datedl.i. .. ... ..� "�
..............................•.
'.C.! 7 Boar of Health
DATE......... / ............................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Barnstable..........................................
Trrtifiratr oaf Tumpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired �X�
t7 P. A x....... ................................................................. -
by.»_.... ... x Installu
ma u i d K e 1?I........................................................... ----------
at_........4311&..�.t�...�.a.... !dill......q......................:................................
has been installed in accordance with the provisions of TITII✓ 5 of The State Sanitary Code as de cri ed in the
`�/...... dated.........! ....-..... .�.`�..........
application for Disposal Works Construction Permit N0...... !
THE dSSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................. 2..-.: .... .. .�.
Inspector...................... ..................... .....................
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:431 0 Route 6A Cummaquid,Mass
Owner: Nancy Hopkins
Date of Inspection: 6/11 /98
BUILDING SEWER:
(Locate on site plan)
3'f
Depth below grade:,L
Material of construction: V cast iron 240 PVC_other (explain)
Distance fr myrivate water supply well or suction line _
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
Joints appear tight No evidence of 1pakagP mhk- c ctam is
vented through the house vent --
SEPTIC TANK: ODCfS
(locate on site plan) ��11��,�.
Depth below grade.g'J Ac."'o �d
Material of construction: L<oncrete _metal —Fiberglass _Polyethylene —other(explain)
If tank is metal, list age VA Is age confirmed by Certificate of Compliance,&A(Yes/No)
Dimensions:/VtOw C11'P'fV1,06 �?-'*
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: rr77
Scum thickness:Z� i-
Distance from top of scum to top of outlet tee or baffle:-7,A�
Distance from bottom of scum to bol,(�t�Ie baffle:
How dimensions were determined
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Pump tank every 2-3 years Inlet and outlet fees
are in place. Liquid level at the outlet invert is fif_tg nnp inrhAc
The tank i s Structurally crninrl ant; hn we nn ci gns of l o;atc^r*9
GREASE TRAP:224pc
(locate-on site plan)
Depth below grade:1VW
Material of construction concrete./)metalAJ�2Fiberglass�l/�PPolyethylene�other(explain)
Dimensions:
Scum thickness:—,dA
Distance from top of scum to top of outlet tee or baHle:_,4M
Distance from bottom of scum to bottom of outlet tee or baffle:_�/
Date of last pumping: A,)&
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage,-etc.)
Grease trap is not present-
(revised 04/25/97) pAge 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4310 Route 6A Cummagyid,Mass.
Owner: Nancy Hopkins
Date of Inspection:6/11 /9 8
TIGHT OR HOLDING TANK (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of constructionAilconcreteA/dmetalAJ Fiberglass.polyethylene. &they(explain)
Q7�
A7/4
Dimensions: ,o.4
Capacity: gallons
o
Design flow: gallons/day
Alarm level:_Alarm in working orderV-4 Yes;426No
Date of previous pumping: _ A.A
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Tight or holding tanks are not prPcan
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Distribution box Has one lateral . No evidence of solids carry over. No
evidence of leakage in or out of the hnx
PUMP CHAMBER: .Ue—
(locate on site plan)
Pumps in working order: (Yes or No)4W
Alarms in working order (Yes or No)�//7'
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Pump chamber is not present
(revised 04/25/97) Page 7 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4310 Route 6A Cummaquid,Mass.
Owner: Nancy Hopkins
Date of Inspection: 6/1 1 /9 8
SOIL ABSORPTION SYSTEM (SAS):z
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number:
leaching chambers, number:
leaching galleries, number:��
leaching trenches, number,length:
leaching fields, number, dirnp{'sions:
overflow cesspool, numberV
Alternative system: 'A/-
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Clay for 22 ' 26 ' dig out was done when installed_ Clean sanr9. wac
hauled in to fill the Pxcavati nn 1 3 ' of sand I-alace the
8 of sand all around the nit and stone lining N�-,igns�lfhTdraulic
failure or ponding_ All ygr�atatinn ig nnr -�m1 c pjt ; ntallPrl
CESSPOOLS: Zlifle,
(locate on site plan)
Number and configuration: 0
Depth-top of liquid to inlet invert:
Depth of solids layer: A)
Depth of scum layer:
Dimensions of cesspool: .424
Materials of construction:
Indication of groundwater: AIA
inflow (cesspool must be pumped as pan of inspection)
Cesspools are not Present
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Cesspools are not present.
PRIVY:YLUe
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids: A)lt
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Privies are not Present.
(sevimed 04/25/97) P&g• 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 4310 Route 6A Cummauid,Mass.
Ovvner: Nancy Hopkins
Date of inspection: 6 11 /98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least rwo,permanent references landmarks or benchmarks
locate all wells within 106' (Lc cate where public water,supply comes into house)
go
i
I
I
/
o � i )
I
i
trwi••d G /15/!7) P•y• 9 of 10
SUBSURFACE SEWAGE DISP•. t. SYSTEM INSPECTION FORM
I C
SYSTEM INFOI. 'IOv (continued)
Property address: 4310 Route 6A Cummaquid,Mass.
Owner: Nancy Hopkins
Date of inspection;6/1 1 /98
Depth to Groundwater /Feet
Please indicate all the methods used to determine High Groundwater EIL-:a:ion:
Obtained from Design Plans on record
Observation of Site (Abusing property observation hole, basemdrA,simp etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
::
Che k pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundva,er E levation. Must be completed)
Used water contours map.
Gaherty & Miller Model
12/16/94
In 1987 when system was installed we excavated a hole
for 22 ' No water was encountered at that time.
(r.vl..d 0//25/97!
L
y •nrnrw -n•rr�.•+-+-trnrmr•nmrfv�.rtrs+risrmr.�r-rsrm►r�rrrarmn rre'n'stfiro'�rsaat mc•. -. i-n-'-rr.�r-.r. :..t-.r
TOWN OF Rarnctahl p LIOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
�. F•.•rn�T•..•;. --..r.-.-r�m�mrt.Trft•snrmsrr+TRrr--ti'trnvrnr�ernmrrmmewrnrmmn.:tw�crf rsm n-ns.rnrto-.rr•r+rr•.r.•.-.,r
-TYPL OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 4310 . Route 6A Cummaquid,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Nancy Hopkins
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Sogf 'Inc.
COMPANY ADDRESS Box 66 Centerville,Mass. 02632.
Strout Town or City Stat• Llp
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 -1578
A
CERTIFICATION STATEMENT
I certify that have• y I personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on
site sewage disposal systems .
Check one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
!health or the environment as defined in 310 CMR 16 - 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
r ,
The inspection which I have con Lcted has found that the system fails to
protect the public health and the environment in accordance with Title
6 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature L Date 6/11'/98
One copy of this c tification must be providod to the OWNER, the BUYER
( where applicable ) and the DOARD OF 11BAL1`lt.
* If the inspection FAILED, the owner or"" perator shall u
within one year of the date of the inspection, unless allowed dortrequiredm
otherwise as provided in 3.10 CMR 16 . 305 .
partd .doc
w
s
- S byv 3�of
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the
General Laws. Issued by The Department of Environmental Protection.
Juno 8. I V')5
Acting Dirccior of the.. l) ion of Water Pollution Control �,
%
GATE : 10J7/03----
PROPERTY ADORE SS : 4310 Route 6A
Cummaq---- --------------
Mass 02637
-- -- ---------------- -- MAP
PARCEL. 3®_
p
On the aoove dale, I inspected the septic system-,at the above a��i�ress.
This system Consists of the following:
1 . 1 -1500 gallon septic tank. 3A. 0-. g out wa.6 oea�o2med heae.`
2. 1 -Distribution Box. RECEIVED3. 1 -6 x 10 leaching pit packed in stone
Baseo on my inspection, I certify the lollowing condllions: NOV 1 3 2003
4 . This is a title five septic sy'stem ( 78 code)
5. The septic system' is in proper working order at TOWN OF BARNSTABLE
present time. HEALTH DEPT.
6. The system was installed with a 26 ' dig out and
clean sand brought in to the depth of 22 ' .
7. Cottage was not inspected at this time..
8. Oa.6te watea i.3 86" geiow the � GNATUR
�74e
pipe o/ the teaching p-.t. — --:-- _ -- - -
Name
ompany : )Q�pph Son, Inc ,
----- - ------
Ceru2:Y LLLe-- Ja - _2Z632-0066
T„iS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
)OSEPH P. MACOMBER & SON, INC.
T ink s-Cesspools•Leachlletds
Pvmped & Inst+llod
Town Sewer Connections
P 0 Box 66 Cente(vilte, MA 02632.0066
)75.3338 775.6412
�\ COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 4310 Route 6A
Cummag, Ma
Owner's Name:Peter Tolan
Owner's Address: same
Date of Inspection: 10 7-TO 3
Name of Inspector: (please print) J.P: maeomber Jr
Company Name: Joseph P. Macomber & son Inc
Mailing Address: Box 66
Centerville
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000Z. The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local'Approving Authority'
Fa'
Inspector's Signature• Date:
The system inspector sh ubmit 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.
Notes and Cornments
****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 . r
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4310 Route 6A
Cutnmaguid Ma
Owner: 1 n
Date of Inspection: 1 0 7 03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
no I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The zeptic zyZziem .is .in paope2 woaking oade2
rl� tho R2o.6ent t cme
B. System Conditionally Passes:
no 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 foll
explain. owing statements. if"not determined"please
no 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:
no Observation of sewage backup or break out or high static water level in the distribution
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(witthroken or
approval of Board of Health):
na broken pipe(s)are replaced
na obstruction is removed
na distribution box is leveled or replaced
ND explain:
_nc 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):
na broken pipe(s)are replaced
na obstruction is removed
ND explain:
t
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMFi�!',S
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORS;
PART A
CERTIFICATION(continued)
Property Address:4310 Route 6A
Cummagtii
OwnerPeter Tolan
Date of Inspection: 1 0/1'7/03
C. Further Evaluation is Required by the Board of Health:
no Conditions exist which require further evaluation by the Board of Health in order to determine il'!;;e
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) th; the
system is not functioning in a manner which will protect public health,safety and the environment:
na Cesspool or privy is within 50 feet of a surface water
na 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:
no The system has a septic tan k and soil absorption system (SAS)and the SAS is within 100 feet 0f
surface water supply or tributary to a surface water supply.
no The system has a septic tank and SAS and the SAS is within a Zone I of a public water sLrgp;y.
no The system has a septic tank and SAS and the SAS is within 50 feet of a private water
_RoThe system has-a septic tank and SAS and the SAS is less than )00 feet but 50 feet or more from
private water supply well••. Method used to determine distance Vz Luc Q
"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 facilit,;and,
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that nc of"her
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
None
3
Page 4 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION(continued)
Property Address: 4 310 route 6A
Cummaguid
Owner: Peter Tolan r.,
Date of Inspection: 10 03
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 i
_ ,� I��pt� 6 xJe
_ squid depth irt� s ess than 6"below invert or available volume is less than hi 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.
:i� Any portion of a cesspool or privy is within a Zone 1 of a public well.
iAny 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. (Tbis 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.)
11C.�(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
_ �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((nterim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a.
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page S of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTA.RY
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION Qr:^•i
PART B
CHECKLIST
Property Address: 4 31 0 Route 6A
Cummaqui
Owner: Peter Tolan
Date of Inspeetlon 1 0 -03 r�
Check if the following have been done.You must Indicate"Yes"or"no" as to each ort' e
Yes No
✓Pumping information was provided by the owner,occupant,or Board or Health
`� Were any of the system components pumped'out in the previous two w«;;s
_ Has the system received normal !lows in the previous two week period?
Have large volumes of water been introduced to the system recently or as p:.;-t c•i
✓ _ Were as built plans of the system obtained and examined?(If they were not av;.i;A is i.,.;
�✓_ 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,41eluding the SAS, located on site ?
I-G — Were the septic tank manholes uncovered,opened,and the intericr c, !,,c ;�::;, ,:•;; ;-;�c ;.. ;;.- � •
Of the baffles or tees, material of construction, dimensions,depth of I'-jid,
Was the facility owner(and occupants if different from owner
maintenance of subsurfa4e sewage disposal systems ? )proviacJ
The size and location or the Soil Absorption System (SAS)on the site leas been C'ettn t r,c
YeiG. _
Existing information. For example, a plan at the Board of HcL;:-Ii.
Determined in the field(i(any of the failure criteria rcl_tcd to --,i C :. .... _ .
is unacceptable)(310 CMR 1 S•302(3)(b))
j
S
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 4310 Route 6A
Cumma u i d
Owper: _Peter 191 an
Date of Inspection: 1117/03
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x M of bedrooms): a 40 D
Number of current residenu: 2
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no):= {if yes separate inspection required)
Laundry system inspected (yes or no)r,,_
Seasonal use: (yes or no): no
Water meter readings, if available (last 2 years usage(gpd)):2001=50, 000 ga-e-eonz 136. 99 CIAO
Sump Pump(Yes or no):__no = ¢.Q.Qon,6=120. 5 5 g10D
Last date of oeeupaneypXe,5,nt
COMM ERCLAL KDUSTRIAL
Type of establishment: NA
Design now(based on 310 CMR 15.203): d
Buis of design now(scatslpersons/sgft,ctc.):
Grca.sc trap present;yes or no): /U
Indusrrial waste holding unk present (yes or no): NA
Non•saniury waste discharged to the Title S system (yes or no):&A
Water meter readings, if available: NA
Last date o(occuparcy/use: NA
OTHER(describe): NA
Pu GENERAL INFORMATION
m'pinQ Records -
Source of in(ormation: Re Az)a i-ea9—Pe
was system pumped as pan of the inspection(yes or no
I(ycs, volume pumped: 0 ¢allons •• How was quantity pumped determined? NA
Rca.Son for pumping: d n o t 0 LL n2 12
TYPE OF SYSTEM
___2t:Scptic unk, distribution box, soil absorption system
N.CL Single cesspool
A4()— Overflow cesspool
Privy
Sharcd system(yes or no)or yes, atuch previous Inspection records, if any)
N-g.- IMOVativc/A Item itiyc technology, Aruch a copy of the current operation and maintenance contract (to be
obtained from system owner)
1UL Tight tank NO Much a copy of the DEP approval
/La— Other(describe): NA
Approximate age or an components,date installed(if known) and source of information:
Tnct-all rid by i :P Macomber 1 1 /25/87 permit #87 781
Were sewage odors dcltcctcd when arriving at the site (yes or no): no
6
Page 7 of I I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ress:4-41 n Rniit-a (,A
Cttmm�quid
Owoer:Peter Tolan
Date of Inspection: 10 3
r`
BUILDING SEWER(locate on site plan)
it
Depth below grade: 13
Materials of consrructio�t iron✓40 PVC mother(explain):
Distance from private water supply well or suction line: 10 4
Comments (on condition of'oints, venting, evidence of leakage, etc.):
Joints appear fight. Noevidence of leakage. Vented through
ouse venic. -
SEPTIC TANK: 1 500 gallons
_(locate on site plan)
Depth below grade:surf e
Material of cons ovction 2concretcAlo metal 46 fiberglass4b polyethylene
tMothe*xplain)_ a
If tank is metal list age: na Is age confirmed by a Certificate of Compliance(yes or no)',!�)
certificate) (attach a copy of
Dimensions: 1 0 ' 6"L X 5 ' 8"W X 5171111
Sludge depth.
Distance from top of s udgc to bonom of outlet tee or bafflc:zd,:!.!
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: _
Distance from bonom of scum to bottom of outlet tee or baffle: e
Now were dimensions determined: installed
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integTiry, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Liquid level t out-let- i nyprt- iG 1 n lace.
The tank is structurally sound no Si,�ns_Qf. .leakage.
GREASE TRAP: IlQftate on site plan) ram' ✓
Depth below grade: _na
Material of cons truction:dLconcrctei(&metal,VAfiberglass,l�polyethylenc J& ther
(explain): ,�hq
Dimensions: nn
Scum thickness: na
Distance from top of scum to top of outlet lee yr baffle: )na
Distance from bonom of scum to bottom of outlet tee or baffle: na
Date of last pumping: na
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
C�rpase trap is not present
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ''
SYSTEM INFORMATION(continued)
Property Address: 4 31 0 Route 6A
Cumma gui d
Owner: Peter Tolan
Date of Inspection:10/17/0 3
TIGHT or HOLDING TANK:no (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: na
Material of construction:,concrete metal fiberglass A24 polyethylene iJJh other(explain):
na
Dimensions: na
Capacity: na gallons
Design Flow: na gallons/day
Alarm present(yes or no): na
Alarm level:na_ Alarm in working order(yes or no): na
Date of last pumping: na
Comments(condition of alarm and float switches,etc.):
Tight or Holdincr tanksare not present
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth,of liquid level above outlet invert: none
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.):
Di si-ri hnt i nn hnx has one l ai-Pra l No Pyeidence of solida, carry
nyPr_ No evidence of leakage in, or out of box
PUMP CHAMBER: no (locate on site plan)
Pumps in working order(yes or no):na
Alarms in working order(yes or no):na
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Pump c am er not present
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:431 0 Route 6A
Cummaguid
Owner: Peter Tolan
Date of Inspection: 1 0//.7/0 3
SOIL ABSORPTION SYSTEM (SAS): 1�eE(locate on site plan,excavation pot required)
1-61X10' 2each.irzg /2.it. [�.cg out pez�oamed. 26 'wide anti 22, dee12.
If SAS not located explain why:
Located: See Rage 10
Type
x leaching pits, number: 1
t� leaching chambers,number: 0
a leaching galleries,number: 0
leaching trenches,number, length: D
4)d leaching fields,number,dimensions: O
overflow cesspool,number: 0 l
innovative/alternative system Type/name of technology: ri LQ ridgy 2�'C
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
.[=gam ,, 6and In rRay 'Poa 19 ' C.2ean Renkag.2e nand zeaahed at19 ' -22'
O '6jgnb 04 h ydfi01i P' r /(/J�!/2e 02 '?ond-ing So-L.Qb ate lLy ege a .Gon
-Gb R02ma�.
CESSPOOLS: >1Q__(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: �9
Depth-top of liquid to inlet invert: _ na
Depth of solids layer: na
Depth of scum layer na
Dimensions of cesspool: n
Materials of construction•. 3 na
Indication of groundwater inflow(yes or no): na
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cesspools are not present
PRIVY:no (locate on site plan)
Materials of construction: na
Dimensions: na
Depth of solids: na
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Privy is nnt- prpGanf
9
Page 10 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ress431 0 Route 6A
Cummaquid Ma
Owner: Peter Tolan
Date of laspection: 1 0%7/03
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.
r I f
I �..�i ,far'✓;�;��/ .
1
(/ r
i
I +I
10
Page 11 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4310 Route 6A
Cummactuid Ma
Owner
Date of Inspection: 1 0 7 03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 'feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record - if checked, date of design plan reviewed:
Observed site(abutting property/observation hole within I50 feet of SAS)
d Checked with local Board of Health-explain: ifJ/g
Checked with local excavators, inst Ilcrs• (attach documentation)
Accessed USGS database-exp lain:hTTA T0-4w. 144 4'
You must describe how you established the higgh ground water elevation:
1.6ed: Gah?ety 9 (7ii_Ve2 Nodei. 12/16/y4 G2ouad wa.tea eieva.tion.6 agove aea ieveQ
1.6ed: LIS�; . we PP dam -7tIno 199?
l.6ed: US 7-ri1n i a 97 000 1 /I)PJo 17 Annuri0 Ranaez of C/ROund
Wrifo 1992
i op orL—faTi�—
Leaching
Pit l
:cct
Groundwater: Feet Below Bottom of Pit • High Groundwater Adjustment 1.8 ft per Fhmpter Method
Therefore, the vertical separation distance between the bonom
Of the leaching pit and the adjusted groundwater table is ?��`
feet.
11
rnrtn�nw�nT\.n:nw•rrw n."n.�.trwwM1w+Aw►r•�.+rn•AAy,'+rw�tn l�n .''w"-'--�.•-.. .-
TOWN OF BARNSTABT,P BOARD OF HEALTH
3111=11FACF SFWA(;g DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION l
^•Tf1•T••.••.',-T.III.�.�TT1JnRA'.I.1TInR1R./•R�.T1'rt7 rlVnR7.R�T�T�•�A'f�qR\ Iw.l •/•1t•'!'r'•'I�•�. .�. A
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 4310 Route 6A Cummaquid Ma Q2637
ASSESSORS MAP , DLOCK AND PARCEL
OWNER' s NAME Peter Tolan
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J P Macomber & Son InC•.
COMPANY ADDRESSBox 66 Centerville Mass.02632
Streit Tovn or City Slat• iIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1578
w
CCRTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the inror►nation reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one : „
xxxx Systeui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have con acted has found that the system fails to
Protect the j)tlblic healtl, and the environment in accordance with Title
5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature le IDate /� 71-
copy. of this c rt.ification must be provided to the OWNER, the BUYERande
where ayplicable ) and the BOARD OF HEALTH.
IF If the inspection FAILED, the owner or.,operator ehall u d
he
within one year of the date of the inspection , unless allowed ort required
m
otherwise as provided in 3.10 CI,IR 16 . 306 .
partd . doc
E F
Vcu lted AT A7
I � I
I I
I I
I I
I ti I
n
1 I I
101-011
I Icli
2
A5 I
I I
'
r
A7 EXISTING
c� O 5ATH i a► I CLOSET
n
n
\ I I --
' � - - - -
o SLI
04
1 CIN
� H.0 u u u H F
ROOF OF BOX _ r ROOF EDGE
OUT 5ELOW C AV 5ELOW
cli
CLOSET
V-5 1/2"
6 BAT -ITI O c q'-q"
�
-- ------------------- -------- 10.
KNEE WALL A-VI/
3'-rollHIGC; LINEN
1n1n1nCLOSET 5'-111jq'--0l'12 -q 1/2 5 -10 1/2 3 -4 1/2 3
(V v I I
�i MEDIA ROOM STAIR KNEE 'WALL
----------------�=10'�HIGH
+ f HALL #1 14 ,
10 v2" ; BEDROOM #3
0 __
---------------J L-------------
OPEN OPEN 13
41-511 RAILING -' DN RAILING
r ----------------------------- § '
(V - `-- --- ------ -- -- ---- ---'----- ----------------------------------
� KNEE WALL - ----
0
I I
3'-roll NIGH
I I -
1 (V
CLOSET\
KNEE WALL
4'-5" HIGH
ROOF EDGE
®� BELOW
3'-0"
�t
I
O
I N
I
I '
I v
I
I
I I
I I
I I `
I
LINEN
5 9w STAIR
I
HALL #2; '-io v "
I I ,
I
� I
I I '
l 1
� I I
I I
I ,
I A7
r i I p
BEDROOM #2
2 u i I i A7
/ I
� I I
I A7 A7 t
Vaulted
Coiling
00
OAT
I I
I I
I I ,
I
I I
I I OI I
I I
I I �
! I 0
I I r
pcISTING i a � CLOSET '
I ; O
� I I
I
L - - - - -
I sf-I
r ROOF EDGE
M L31
LON
N AV
CLOSET 6'-3 1/2" I G -1'--1"
`9 A A7
+ i A7 O
To _ -
I O
O
O
, A
Q
� EXIST I \
EXISTING , �AA'RAGE I 1
KITCHEN I \
DN
UP
TO
1 i BASEP;'f;ENT \\ \
-1 F
i I \
"-� B X7 \ \
211
i Ally
I IDINING RM I v
II LI A ®� `
2"
II II A'
2"
O A7• F
- J � J L _ A7
F -1 F \
y„ V-6 1 l2'
v / Gi
EXPOSED I I ®® \ ✓/
SEAMS ABO JEI =
i
NEW SED Xt
OFEi�I[ G to Y
HALL
0
CONVERTED EX DR EXISTING O
HALF TO REMAIN LAUNDRY 6'-6" 7"
BATH
SN, ROD m �
®®
ZL
i 6'-8" �
NEW CUED m _
' --
A5 -------
A HALL Q
0
Q
- CONVHA�TED EX. DR, UNDRY O b'-6" 7"
MATH TO REMAIN
sH ROD i)
n
N,
i 6'-8" _�
NEW CIJED `�
O I OPEN INr I
2' G b'-6 1/2"
2'—q" L, A7
A7VIA
K
2" II II _ -
_ EXPOSED SH O
(' -- NA
5EAM5 A50VE ct o MASTER
n I I L I V I NCB ROOM I 10 o °0 BATH - �
OPERAILINGr "
a I 6'-1 1/21, 10'-10
+ - O FLOOR O I o
2" A50VE
S
l l SEAT
4'-0" I
12" DEEP —
500K SHELVES UP 14R n Qit
FLUSH STONE _i O
� 1'-10 i/ " ' 1/2"
le :t]l 'r �UitAI
HEARTH 6 -�
F
to
3 —O
LIN N SH - ROD
O, 5 H — — —
F -------------------------- JI
T ---- o _
® G n ® ® ..
2'—O" 3'-1 1/2" 10'—q i/2" - co 4-5 1/211 CC
MASTER
x4 BEDROOM
o Z—VAULTED
0
CEILING',
= 7
N
c
A5
b -O 5 0 10 q 1/2