HomeMy WebLinkAbout4352 MAIN ST./RTE 6A(BARN.) - Health (2) ^4: 5 Cb AIN'T STREET,= C_UMMAQUID
?ACWORTH'5INN A=S5I- 0391 • •'
Avi
7
i
1�
� � i
i
35/-039
Commonwealth of Massachusetts
Title 5 Official Inspection Form ?
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
.t. Sey`e
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is �
required for every Barnstable MA 02530 4/9/18 �.
page. Cityrrown State Zip Code Date of Inspection,
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information �/
filling out forms
on the computer,
use only the tab 1. Inspector
key to move your
cursor-do not - Joseph R. Smith
use the return Name of Inspector
key.
Bennett Environmental Associates
Company Name
P.O. Box 1743
Company Address
Brewster MA 02631
City/Town State Zip Code
508 896 1706 Sl#4994
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Furthe valuation by the Lo al Approving Authority
4/10/18
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
-- -_- --- - -- — -at-that time.-This inspection-does--not-address how the system will perform in the future under
the same or different conditions of use.
t5ins r 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
401e VS
f
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 4952 Route 6A [Map 351,Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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 working condition and is functioning as intended. None of the failure criteria described in
310 CMR 15.303 or in 310 CMR 15.304 existed at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*,or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis &Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. Cityfrown 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
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•11/10 — Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis &Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El El Area
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•11/10 "' — Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis &Cynthia Ciavarra
Owner Owner's Name
information is
t Barnsable MA 02530 4/ /1
required for every 9 $
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 6 Number of bedrooms (actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
^M
Property Address
Louis &Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. CityTTown State Zip Code Date of Inspection
D. System Information
Description:
Septic System that serves residence is comprised of a 1,500 gallon septic tank, D-box, and a
14'x 48' x 0.5' leaching field [672 GPD provided >660 GPD required].
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d See details
9 ( y 9 (gP ))�
Detail:
2016/2017: 30,000 gallons = 82 GPD; 2017/2018 (Partial -6 Months) : 8,000 gallons=44 GPD
Sump pump? ® Yes ❑ No
Last date of occupancy: Sept 2017Date
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis & Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Seasonal -September 2017
Date
Other(describe below):
Sump pump in the basement is used for water intrusion through foundation from surrounding
landscapes that pitch towards the foundation itself, and due to poorly draining soils
surrounding the foundation as well. Discharge to ground surface outside building. Not
connected to septic system.
General Information
Pumping Records:
Source of information: Homeowner- Pumping record attached as addendum
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis & Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
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:
System upgraded with BOH approval in 1992 (Permit 92-566) - per engineered plan "Site and
Sewage Plan for System Upgrade..." By Down Cape Engineering#92-058 (rev. 4/21/92).
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):
100'+
Distance from private water supply well or suction line. feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Properly vented. No evidence of leakage of joints or backup into building encountered while
inspecting building sewer line.
Septic Tank(locate on site plan):
Depth below grade: 0.5'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,500 gallon septic tank with two PVC inlet tees and one PVC outlet tee fashioned with a gas baffle.
Last pumped 11/22/17-(1500) standard maintenance. Note: At time of inspection the septic.tank
static water level was below normal operating height due to pumping activities and limited use of the
dwelling, 24"of water observed in septic tank at time of inspection.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1,500 gallon
Sludge depth: Oil
t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 4352 Route 6A [Map 351, Parcel 039] -
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. Cityrrown 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
41"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle NA-Tank not at operating height
Distance from bottom of scum to bottom of outlet tee or baffle NA-Tank not at operating height
How were dimensions determined? Tape Measure, Sludge Judge,
Probe
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not recommended at time of inspection. Liquid level as related to the outlet invert is below
normal operating height due to pumping activities conducted on 11/22/17 and is also attributed to
limited use of residence. No evidence of backup or leakage encountered while conducting the
inspection on the septic tank. PVC inlet tees are both in good condition and functioning as intended.
PVC outlet tee fashioned with gas baffle is also functioning as intended. Both inlet and outlet access
covers to within 6"of final grade.
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•11/10 "" Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is Barnstable MA 02530 4/9/18
required for every ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 4352 Route 6A [Map 351 Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
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 Effluent at outlet invert is normal
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is level and distributing effluent to the leaching field equally with no sign of backup. Some
evidence of solids carry-over present in the D-box. No evidence of leakage into or out of D-box
encountered while conducting inspection of the D-box. Minor corrosion of concrete noted below water
line.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 -(48'Wx141x0.5'D )
❑ 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.):
Vegetation in low area appears normal, with no indication of hydraulic failure or ponding present. A
piezometer was installed at the end of the leaching field down to 8.5'; at the time of inspection, the
piezometer contained 18"of water(groundwater observation 84"), correlating with the test hole logs
from the Down Cape Engineering site and sewage plan for system upgrade(3/21/92, Rev. 4/21/92),
wherein water was also encountered at 84"in a monitoring pipe.
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�r 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis& Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 41+
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: Plan Date 3-21-92; Revised 4-21-92
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:
Established estimated depth to high groundwater by referencing site and sewage plan for system
upgrade by Down Cape Engineering, Inc. of Yarmouthport, MA. Test hole logs from plan indicate
groundwater encountered at elevation 27.8. Down Cape Engineering, Inc. also calculated for an
adjusted high water level which was set at a 1.5' difference, placing high water at elevation 29.0. The
bottom of the leaching field is at elevation 33.0, with the adjusted high water level is at elevation 29.0,
4.0' of separation is provided. Additionally, groundwater was observed at 84"through existing
monitoring well on property.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis& Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 4/9/18
page. Cityrrown 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
I
t5ins•11/10 Title Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Invoice
Capewide Enterprises/JP Macomber
A Robert B.Our Co.,Inc.Company Date Invoice#
153 Commercial Street
Mashpee,MA 02649 11/22/2017 3130
508-477-8877 A�
Bill To IV 16
Louis Ciavarra
4352 Main Street
Barnstable,MA 02630
Job No. Terms
23213 Due on receipt
Cluantity Description r x at Amot ...
1 Septic pumping, 1500 gallon tank 11/21/17 299.00 299.00
Thank you for your business!
Please make checks payable to Capewide Enterprises. Total $299.00.
Payments/Credits -$299.00
Balance Due $0.00
wAv
A
Ai
T3
s
dins•09103 TitbS OMcbAuj eetJ=Fom Subsu&cv SewezcDiTosal System-Page 15 of 17
I
i
TOViN OF tl:9RNSTABL) -
SEWAGS#
VILLAGE
ASSESSOR'S M.AP 4r LOT ,
/-1-v3c/
INSTALLER'S NAME & PHONE NO; y�
SEPTIC TANK CAPACITY
v
z.: L
E:riCf1IN0 FACILITY. -^ /- -+•¢'l�.a�, r`• .. .._,� �_ �
a NO, OF BEDROOMS `PRIVATE WELL OR FUB-[* WATER 1'v
BUILDER CUR OBINER Sly,* . p,z !-3 o..✓
I
DATE PERMIT ISSt1ED;
DATE COMPLIANCE ISSU4D,_
------------
VARIANCE CRANTED: Yes
7 to 1Q �
! i l• I l I I
` P oA `3 1
f�
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments
^M 4352 Route 6A [Map 351, Parcel 0391
Property Address �+
r
Louis&Cynthia Ciavarra y
Owner Owner's Name Qy
information is �.
required for.every Barnstable MA 02530 2/1/16
page. Cltyrrown State Zip Code Date of Inspection t i
W
A
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:when filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not .
use the return Joseph R. Smith, IRS
key. Name of Inspector
_ .
Bennett Environmental Associates
Company Name
P.O. Box 1743
Company Address
Brewster . MA 02631
City/Town State Zip Code
508,896 1706 : - .:: :SI #4994
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that.the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on,my training and experience in the Lproper function and maintenance of on site
sewage disposal systems. I am a PEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system: -
E Passes ❑ Conditionally:Passes ❑ Fails --
❑ Needs Fu Evaluation by the Loc Approving Authority
- 2/2/16. -:
ector'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.
p Y _ inspection and under
****This re ort onl describes conditions at the tame of ins 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
-a
C/
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
rt� o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 2/1/16
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/a/wayscomplete all of Section D
A) System Passes:
® 1 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 working condition and is functioning as intended. None:of the failure criteria described in
310 CMR 15.303 or in 310 CMR 15.304 existed at the time of inspection.
13) 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 complyingse tic tank as approved b the Board of
P 9 p p Pp Y
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 than20 years old is available:
Y ❑ N ❑ ND (Explain below):
t5ins•11/1.0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
N
w Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 2/1/16
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cost.):
❑ 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):
El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction Is removed ❑ Y ❑ N ❑ ND (Explain below):.
El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
c
Commonwealth of Massachusetts
9
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039] -
Property Address:
Louis &Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 2/1/16
page. Cltylrown 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:
0 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.watersupply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
0 The system has aseptic tank and SAS and the SAS is with in.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
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
El ® or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below.invert or available volume is less
® than '/day flow
t5ins•11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 4 of 17.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4352 Route 6A [Map 351; Parcel 039]
Sy.
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is Barnstable MA 02530. 2/1/16
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cone.)
Yes No
0 ® 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
El ® tributary to:a:surface water supply..:
❑ ® Any portion of a cesspool or privy Is within a Zone 1 of a public well.
Any portion of.a cesspool or privy is within 50 feet of a.private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and.nitrate nitrogen is equal to or less than . 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.
El I 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.thefailure.
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
El - El Area-1WPA) 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•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
-
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'p 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis &Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 2/1/16
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
El ® 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 recentlyor as:part.of
El ® this inspection?
® ElWere 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 breakout?
Z ❑ 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?
® ElWas 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): 6 Number of bedrooms(actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
660
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
4352 Route 6A {Map 351, Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 2/1/16
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Septic System that serves residence is comprised of a 1,500 gallon septic tank, D-box, and a
14' x 48' x 0.5' leaching field [672 GPD provided >660 GPD required].
Number of current residents: not known
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
Seasonaluse? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d See details
9 ( Y 9 (gP ))�
Detail:
2014: 91,000 gallons=249 GPD; 2015: 15,000 gallons=41 GPD
Sump pump? ® Yes ❑ No
Last date of occupancy: Used Seasonally
Date
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 tankpresent. El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 'r 4352 Route 6A [Map 351, Parcel 039]
Property Address. .
Louis&Cynthia Ciavarra
Owner Owner's Name
information is
requiredforevery Barnstable MA 02530 2/1/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
currently in.use-Seasonally
Last date.of occupancy/user
Date
Other(describe below):
Sump pump in the basement is used for water intrusion through foundation from surrounding .
landscapes that pitch towards the foundation itself, and due to poorly draining soils
surrounding the foundation as well. Discharge to ground surface outside building. Not
connected to septic system.
General Information
Pumping Records:
Source of information: Town of Barnstable -Board of Health :
Was system pumped as part of the inspection? El 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 currentoperation:and .
= maintenance contract(to be obtained from system owner):and a copy of latest inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System_•Page 8 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name -
information is required for every Barnstable MA 02530 2/1/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont:)
Approximate age of all components, date installed (if known) and source of information:
System upgraded with BOH approval in 1992 (Permit 92-566)- per engineered plan "Site and
Sewage Plan for System.Upgrade.L" By Down Cape Engineering#92-058 (rev. 4/21✓92)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth:below grade: - -
feet
Material of construction:.
❑ cast iron ®40 PVC ❑ other(explain):
100'+
Distance from private water supply well or suction line: feet.
Comments (on condition ofjoints, venting, evidence of leakage, etc.).
Properly vented. No evidence of leakage of joints or backup into building encountered while
inspecting building sewer line.
Septic Tank(locate on site plan):
0.5' .
Depth below grade:
feet.
Material of construction:
® concrete
❑ metal El fiberglass: ❑ polyethylene ❑ other(explain)
1,500 gallon septic tank with two PVC inlet tees and:one PVC outlet tee fashioned with a gas baffle.
Last pumped 3/8/12 -(1500) standard maintenance.
If tank is metal, Fist age: years
Is age confirmed by a Certificate of Compliance? (attach,a copy of certificate) ElYes ❑ No
1,500 gallon
Dimensions:
0"
Sludge depth:
.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
yve 4352 Route 6A [Map 351, Parcel 0391
Property Address
Louis&Cynthia Ciavarra
Owner Owner's Name
information is
required for every Barnstable MA 02530. 2/1/16
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont:)
Septic Tank(coat.)
Distance from top of sludge to bottom of outlet tee or baffle 41"
011
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined?. Tape Measure, Sludge Judge,
Probe
_Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not recommended at time of inspection. Liquid level as related to the:outlet invert is at a
normal operating height. No evidence of backup or leakage encountered while conducting the
inspection on the septic tank. PVC inlet tees are:both in good condition and functioning as intended.
PVC outlet tee fashioned with gas baffle is also functioning as intended.
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
Dateof last pumping: .
Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis& Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 2/1/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural-integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete El metal: Elfiberglass Elpolyethylene Elother(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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
_ - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A (Map 351, Parcel 0391
Property Address
Louis &Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 2/1/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert Effluent at outlet invert is normal
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is level and distributing effluent to the leaching field equally with no sign of backup. Some
evidence of solids carry-over present in the D-box. No evidence of leakage into or out of D-box
encountered while conducting inspection of the D-box. Minor corrosion of concrete noted below water
line.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 112 of 17
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis &Cynthia Ciavarra
Owner Owner's Name
information is
required for every
Barnstable MA 02530 2/1/16
page. City/Town State Zip Code Date of Inspection
D. System..Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:-
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 -(48'W x 141 x
0.5 D )
❑ 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.):
Vegetation in low area normal with no indication of hydraulic failure or'ponding present. A piezometer
was installed at the end of the leaching field down to 8.5' and did not encounter any water and found
to be dry at time of inspection.
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 13 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
m e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7M
4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis &Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 2/1/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition.of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis& Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 2/1/16
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis& Cynthia Ciavarra
Owner Owner's Name
information is required or every
Barnstable MA 02530 2/1/16
f
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4+
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: Plan Date 3-21-92; Revised 4-21-92Date
❑ 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:
Established estimated depth to high groundwater by referencing site and sewage plan for system
upgrade by Down Cape Engineering, Inc. of Yarmouthport, MA. Test hole logs from plan indicate that
groundwater was encountered at elevation 27.8.Down Gape Engineering, Inc.also calculated for an
adjusted high water level which was set at a 1.5' difference, placing high water at elevation 29.0. The
bottom of the leaching field is at elevation 33.0 and the adjusted high water level is at elevation 29.0,
providing 4.0' separation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 4352 Route 6A [Map 351, Parcel 039]
Property Address
Louis &Cynthia Ciavarra
Owner Owner's Name
information is required for every Barnstable MA 02530 211/16
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
f �y
-s
VO
t5ius•09108 Title 5 Official laspectionForm:Subsurface Sewage Disposal System•Page 15 of 17
fN; ?-'_3 TOWN OF BARNSTABLE
,0CA7Jo '
SEWAGE
ASSESSOR,s M.AP C,
INSTALLER'S NAME a PHONE ?40,A.
SF-MC TANK CAPACITY IS_ 00_, Z td
LEACHING FACILITY.(cy�e)
(size)
NO, OF BEDROO&fS 1611'
---PRIVATE WELL OR PUB'6 WATER
il
BUILDER OR OWNER •0 i
DATE PERMIT ISS V
DATE coMpL ONCE ISSU ' -------I-------
ED,
VARIANCE CRANTED: yes
4
-t jig TO
balmc A
2
.1- , J
1 i�,J � j '"t i ��'
1/3 0
� �,�•,, �.J,fY�, c �� g*��^c- a�t, �fta"���1ti �;,.. �i���d., ` � :�
��V�jµ���� sw'r �c y mot} � �`��,���` �'+•�y. „��;xii�-'�ta''t 99' rs i��3"h 4a�3's' '
ba
s `'i•
fi.A s:,L
Icc�a4•'_d3'"�F�rt', '. v t a ' '�SFt,,
f Y" T" .@,:".
cry�.:*�.` ., »x
c
�- �� ia��'} :�� � , k,�' a t " t »� ,^ • �` ' "'Esc "„
} w"r+�r�y�:'aL`•ak,.� x a,,�c,1r .'� �a. '&�` �i."i,:"Vy. �T`a` � `9
1 i• 1 i•
f
Message Page 1 of 2
Miorandi, Donna
From: Mary Joyce [Mary.Joyce@joyceandjoyceassoc.com]
Sent: Wednesday, August 13, 2014 8:37 AM
To: Miorandi, Donna
Subject: Re: 4352 Main St., Route 6A, Barnstable MA 02630
Donna,
Thanks so much for your assistance.
Sincerely,
Mary S. Joyce, Esq.
Joyce & Joyce Assoc.
411 Main St., Building 1, Unit A
Yarmouthport, MA 02675
T: (508) 375-9093
F: (508) 375-9094
On Aug 13, 2014, at 8:21 AM, "Miorandi, Donna" <Donna.Miorandi(a),town.barnstable.ma.us> wrote:
Good Morning Ms. Joyce: You are all set for 4352 Main St., Barnstable. I shall put all these
documents in the file for this address.
Donna Miorandi, R.S.
Town of Barnstable
Health Inspector
-----Original Message-----
From: Mary Joyce [ma i Ito:Mary.JoyceObjoycea ndioyceassoc.com]
Sent: Tuesday, August 12, 2014 1:37 PM
To: Miorandi, Donna
Cc: acworthinn(abcomcast.net
Subject: 4352 Main St., Route 6A, Barnstable MA 02630
Dear Donna,
As we discussed, attached please find the septic pumping records for the last three
years for 4352 Main St., Route 6A, Barnstable, MA to supplement the septic
inspection report for the property dated Aug. 21, 2012. 1 have also attached a copy
of the certificate of compliance and the regulations stating that the report can be
relied on for three years within date of closing with said pumping records. The
closing is scheduled for Sept. 12, 2014.
I
9/9/2014
Message Page 2 of 2
Can you please confirm receipt and that we are all set?Thank you.
Sincerely,
Mary S. Joyce, Esq.
Joyce &Joyce Assoc.
411 Main St., Building 1, Unit A
Yarmouthport, MA 02675
T: (508) 375-9093
F: (508) 375-9094
9/9/2014
Y .
310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION
f
15.300: continued
(5) Facilities with an increase in the nitrogen loading rate in accordance with 310 CMR
15.262(6) and(7)shall be inspected annually. The inspection shall document at a minimum:
whether the system has been continually operated as approved; if the system consists of a
greywater filter, whether it is operating properly; and whether compost and blackwater are
disposed of off-site in accordance with all applicable laws and regulations. The results of each
annual inspection shall be submitted to the Department and the Local Approving Authority by
January 311 of the following year.
15.301: System Inspection
(1) Inspection at Time of Transfer. Except as provided in 310 CMR 15.301(2), l 5.301(3),and
15.301(4),a system shall be inspected at or within two years prior to the time of transfer of.title
to.the facility —A �,the cysternf An inspection conducted up to three;:years before the time
o ns er niay lre;used if the inspection report rs accompahied.by system pumping record's
demonstrating that the system°l as beeti pumped�at least,once asyear during that time;.If weather
onditions preclude inspection at the time of transfer,the inspection may be completed as soon
as weather permits,but in no event later than six months after the transfer,provided that the,
seller notifies the buyer in writing of the requirements of 3 10 CMR 15.300 through 15,305. A
copy of the complete inspection report shall be submitted to the buyer or other person acquiring
title to the facility served by the system.
(2) The following transactions shall not be considered transfers of title for the purposes of
310 CMR 15.301(1):
(a) taking a security interest in a property, including but not limited to issuance of a
mortgage;
(b) refinancing a mortgage or similar instrument,whether or not the identity of the lender
remains the same;
(c) a change in the form of ownership among the same owners,such as placing the facility
within a family trust of which the owners are the beneficiaries,or changing the proportionate
interests among a group of owners or beneficiaries;
(d) adding or deleting a spouse as an owner or beneficiary;or a transfer between spouses ,
during life,out right or in trust;or the death of a spouse;
(e) the appointment of or a change in a guardian,conservator,or trustee.
(3) Applicability to Specific Transfers of Title.
(a) Units in a Condominium or Cooperative Corporation. The cooperative corporation or
condominium association shall be responsible for the inspection,maintenance,and upgrade
of any system or systems serving the units,unless otherwise provided in the governing
documents of the condominium association or the cooperative corporation. For a facility
comprised of five or more condominium or cooperative units,each system located on the
facility shall be inspected at least once every three years instead of at time of transfer of title
and all existing systems shall be inspected by December 1, 1996. For a facility comprised
of fewer than five condominium or cooperative units:
1. each system located on the facility shall be inspected at least once every three years
and all existing systems shall be inspected by December 1, 1996,or
2. at the time of transfer of title of any unit, the system serving that unit shall be
inspected in accordance with the time of transfer provisions of 310 CMR 15.301.
f
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTA.BLE,.MASSACHUSETTS
(Certificate of (ConWlia nee
THIS IS To CERTIFY,that the Ou-site Sewage Disposal System Constructed ( ) Repaired (✓) Upgraded ( )
Abandoned( )by q.,Mg s.,���„r
at �„� L /YI a has b en c ns cted in c rdsnee
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer ..430
#bedrooms Approved derAw flow gpd
The issuance of this pprmi4shall not be construed as a guarantee that the syste wM as esigned.
Date I Inspector
-------------> -� ,----------- --- --- ---r---+�-----
i
d LL6�1 '0N NVEZ :ll tilOz S 2nv
GOD CHG
NgVftmood
508-775-2820 MM DD YY JOB#
300 Main Street 508.945-6111 ltli�� EQ+
West Yarmouth, MA Q2673 (Tou Free)855-775-2820 Date L� �✓
TECH NAME �-
SITE INFORMATION ILLING INFORMATION
Name �-U'ame
Address Address
City 00hAMA 'LLfjn-,'r__State Aj�&Zp { ¢ City State Zip
Phone phone
Ernall
WORK TO BE PERFORMED:
SEPTIC-
TOTAL:. S .�U
JOB NOTES:
LABOR:
TECH START END TECH START END OT/CHG
MATERIALS:
QUANTITY ITEM/DESCRIPTION PRICE PO#
TERMS: CHECK#
CC#
EXP. DATE
Customer Signature X + Date
Print Name
Te 3J17d dsn b0E09L£8aS Se:bT bTOZ/80/8e
NEIGHBORHOOD WASTE WATER Invoice
SERVICES
o ce
W YARMOUTH,MA 02673 Date Invoice#
350 MAIN STREET 3/22/2013 1820
TIM
Bill To Job Site
ACWORTH INN BED&BREAKFAST ACWORTH INN BED&BREAKFAST
LISA CALLAHAN 4352 ROUTE 6A
PO BOX 256 CUMMAQUID,MA 02637
CUMMAQUID MA 02637 508-362-3330
t P.O. Number Terms
Due on receipt
Price c Description nce Ea h Amount
SERVICED 1500 GALLON SEPTIC TANK 3/22/2013 309.00 309.00
DISCOUNT -20.00 -20.00
4
Subtotal $289.00
Payments/Credits $289.00
Payments not received within 30 days will result in a finance charge of 1.5%per
month or an annual percentage rate of 18%. Balance Due $0.00
Please make checks payable to Neighborhood Waste Water
Services.Thank You.
Phone: 508-775-2820 Fax: 508-778-9628
AF
:Y M -
�
ij.a
D
OR
5CRUMON of
LABOR F
D� 1
DMN Q,
T•�i tas ?roN . . .... . . '.
Corr�Acx'� 't� . _ • � �
T Ct�NstaucrroN.
CANCO PAC r y
j �17[ t�G
LABQR
P I. F�
S�Rnce CALL
.MPt L E
Fua.SuRCHARW
Mnwtu
SAu=s TM
Q FtnalOEsc stc PW-E Po.#
StlB7�{Ak. ,
Tt►rai.A�xot�errr:t�� `. ,.7�'�. '�®
S3A'ffL,t,S:: GbMPLETFt3 AZ/ REKVWULED�� CANMO. Coco mi F.ou.ow tp 0.
rf 77.
CHSCW� _ CAsl'AW 711E SERVICES;R 'J3S$AT KC COFt1f'
PAYMENT �
INi:'a�tenaTloN
GC
. COD CHG
Nt�1bOA100d .
50&-775-2820 MM DD YY JOB#
300 Main Street 508-945-6111 (� j
West Yarmouth, MA Q2673 (Tou Free)855-775-2820 Date I— 1 &6
TECH NAME
SITE INFORMATION IL.LING INFORMATION
Name e -NetCle
Address Address
city yy _StsteAJA Zp f City Slate Zip
Phone Phone
Emil
WORK TO BE PERFORMED: '
TOTAL:
JOB NOTES:
LABOR:
TECH START END TECH START END OT/CHG
MATERIALS:
QUANTITY ITEM/DESCRIPTION PRICE PO#
TERMS: CHECK# � _
CC#
EXP. DATE
o
Customer Signature X �. Date
Print Name
t0 3�bd vsi-i b0809LE80S 58:hZ VTOZ/80/80
310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION
15.300: continued
(5) Facilities with an increase in the nitrogen loading rate in accordance with 310 CMR
15.262(6)and(7)shall be inspected annually. The inspection shall document at a minimum:
whether the system has been continually operated as approved; if the system consists of a
greywater filter, whether it is operating properly; and whether compost and blackwater are
disposed of off-site in accordance with all applicable laws and regulations. The results of each
annual inspection shall be submitted to the Department and the Local Approving Authority by
January 31'of the following year.
15.301: System Inspection
(1) Inspection at Time of Transfer. Except as provided in 310 CMR 15.301(2), 15.301(3),and
15,301(4),a system shall be inspected at or within two years prior to the time of transfer of title
to.the facili v..'S y rhP s stY emf An inspection conducted up to three;years before the.time
o ns er'nfiiiy be,used if the.inspeeton report is aceon1panied:bem pumping records gsyst
demonstrating that the 9ysteni has beeti pumped°at least,once a year during that time,. If weather
onditions pi dcl'ude inspection at the time of transfer,the inspection may be completed as soon
as weather permits,but in no event later than six months after the transfer,provided that the
seller notifies the buyer in writing of the requirements of 310 CMR 15,300 through 15,305. A
copy of the complete inspection report shall be submitted to the buyer or other person acquiring
title to the facility served by the system,
(2) The following transactions shall not be considered transfers of title for the purposes of
310 CMR 15.301(1):
(a) taking a security interest in a property, including but not limited to issuance of'a
mortgage;
(b) refinancing a mortgage or similar instrument,whether or not the identity of the lender
remains the same;
(c) a change in the form of ownership among the same owners,such as placing the facility
within a family trust of which the owners are the beneficiaries,or changing the proportionate
interests among a group of owners or beneficiaries;
(d) adding or deleting a spouse as an owner or beneficiary;or a transfer between spouses
during life,out right or in trust;or the death of a spouse;
(e) the appointment of or a change in a guardian,conservator,or trustee.
(3) A�plicability to Specific Transfers of Title.
(a) Units in a Condominium or Cooperative Corporation. The cooperative corporation or
condominium association shall be responsible for the inspection,maintenance,and upgrade
of any system or systems serving the units, unless otherwise provided in the governing
documents of the condominium association or the cooperative corporation. For a facility
comprised of five or more condominium or cooperative units,each system located on the
facility shall be inspected at least once every three years instead of at time of transfer of title
and all existing systems shall be inspected by December 1, 1996. For a facility comprised
of fewer than five condominium or cooperative units:
1. each system located on the facility shall be inspected at least once every three years
and all existing systems shall be inspected by December 1, 1996,or
2. at the time of transfer of title of any unit, the system serving that unit shall be
inspected in accordance with the time of transfer provisions of 310 CMR 15.301,
F
THE COMMONWEALTH OF MA,SSACHUSETTS
BARNSTABLE, "SACHUSETTS
Certificate of CanWhatite
TMS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( V) Upgraded.( )
Abandoned( )by 41�.e �
at � � _ has b en jasycted in rdance
with the provisions of Title Sand the for Disposal System Contraction Permit No, 7;/,9
dated
b
Installer Designer
#bedrooms Approved de i flow gpd
The issuance of this rtni shall not be construed as a guarantee that the syste will fu �aNsekmgned.
�Date �10 1 Inspector
-- --------- -- ----------- ——— ---Y----,�-----
i
1 d LLIE� 'ON wd�z ��oz 5 2nd
i -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M ,•°'�~ 4352 Route 6A-Acworth Inn (Map 351, Parcel 0391
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 8/15/12
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see
completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer, t
use only the tab 1. Inspector: v I
key to move your
cursor-do not use David C. Bennett, IRS
the return key. Name of Inspector a
fab Bennett Environmental Asscoiates, Inc.
Company Name
,enm, 1573 Main Street/P. O. Box 1743
Company Address
Brewster MA 02631
City/Town State Zip Code
(508) 896-1706 S11299
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Furth valuation by the Local Approving Authority
8/21/12
In ect ' 'gn Date
The system i spe r 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page I of 17
s
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 8/15/12
Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 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):
Precast outlet tee in septic tank is cracked, to be replaced by PVC tee with gas baffle. System is in
working condition and is functioning as intended. None of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 existed at the time of inspection.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 8/15/12
Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
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):
Replace cover on D-box.
❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 8/15/12
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
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 Y day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 8/15/12
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I ,
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M ,• 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 8/15/12
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?
® El Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
A System Information
Residential Flow Conditions:
Number of bedrooms(design): 6 Number of bedrooms (actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 8/15/12
City/Town State Zip Code Date of Inspection
A System Information
Description:
Septic System that serves bed and breakfast is comprised of a 1,500 gallon septic tank, d-box, and a
14'x 48'x 0.5' leaching field [672 GPD provided > 660 GPD required].
Number of current residents: not known
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See Details
9 ( Y 9 (gp ))�
Detail:
2009- 114,000 gallons = 312 GPD; 2010-99,000 gallons=271 GPD; 2011 - 103,000 gallons= 283
GPD
Sump pump? ® Yes ❑ No
Last date of occupancy: Currently in use
Date
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 8/15/12
CityfFown State Zip Code Date of Inspection
A System Information (cont.)
Last date of occupancy/use: currently in use
Date
Other(describe below):
Sump pump in the basement is used for water intrusion through foundation from surrounding
landscapes that pitch towards the foundation itself, and due to poorly draining soils
surrounding the foundation as well. Discharge to ground surface outside building. Not
connected to septic system.
General Information
Pumping Records:
Source of information: Town of Barnstable Board of Health
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
*M 4352 Route 6A-Acworth Inn [Map 351, Parcel 0391
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 8/15/12
Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System upgraded with BOH approval in 1992 (Permit 92-566)-per engineered plan "Site and
Sewage Plan for System Upgrade..." By Down Cape Engineering#92-058 (rev. 4/21/92).
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: 100'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Properly vented. No evidence of leakage of joints or backup into building encountered while
inspecting building sewer line.
Septic Tank(locate on site plan):
Depth below grade: 0.5'feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,500 gallon septic tank with concrete inlet and outlet tees. Precast outlet tee cracked as needing
replacement. Last pumped 3/8/12 -(1500) standard maintenance.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10'6"Lx68"Wx5'8" H
Sludge depth: 311
- t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 8/15/12
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
38"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape Measure, Sludge Judge,
Probe
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not reccomended at time of inspection. Liquid level as related to the outlet invert is at a
normal operating height. No evidence of backup or leakage encountered while conducting the
inspection on the septic tank. PVC inlet tee is in good condition and functioning as intended. Precast
outlet tee cracked as could result in solids carryove V nditional pass based on replacement of outlet
tee with PVC tee and gas baffle.
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
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 0391
Property Address
Lisa Callahan
Owner information Owner's Name a
is required for
every page. Barnstable MA 02530 8/15/12
Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 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
^M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 8/15/12
City/Town State Zip Code Date of Inspection
A System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Effluent at outlet invert is normal
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is level and distributing effluent to the leaching field equally with no sign of backup. Some
evidence of solids carryover present in the D-box. No evidence of leakage into or out of d-box
encountered while conducting inspection of the D-box. Minor corrosion of concrete noted below water
line. Recommend replacement of D-box cover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Leach field location per plan probed.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M O' 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 8/15/12
City/Town State Zip Code Date of Inspection
A System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 - (48'W x 141 x
0.5 D )
❑ 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.):
Vegetation in low area normal with no indication of hydraulic failure or ponding present. A piezometer
was installed at the end of the leaching field down to 8.5' and did not encounter any water and found
to be dry at time of inspection under peak seasonal use.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 8/15/12
City/town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM ,. 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 8/15/12
City/Town State Zip Code Date of Inspection.
A 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
9
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 8/15/12
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: 4+
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: Plan Date 3-21-92 ; Revised 4-21-92Date
❑ 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:
Established estimated depth to high groundwater by referencing site and sewage plan for system
upgrade by Down Cape Engineering, Inc. of Yarmouthport, MA. Test hole logs from plan indicate that
groundwater was encountered at elevation 27.8, Down Cape Engineering, Inc. also calculated for an
adjusted high water level which was set at a 1.5'difference placing high water at elevation 29.0. The
bottom of the leaching field is at elevation 33.0 and the adjusted high water level is at elevation 29.0
which provide a 4.0 foot seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
' I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M s•°''� 4352 Route 6A-Acworth Inn [Map 351, Parcel 0391
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 8/15/12
Cityfrown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
g
A�
kt IzA.,0
S
1 Z - V0 ;5
S so
a
e5
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
TOWN OF
L0CATlON, ?,e-3-Q1 SEWAGE #
VILLAGE J�
-= ASSESSOR'S M.AP ,Sr /-U3CI
INSTALLER'S. NAME a PHONE NO,A. , .. I I
SEPTIC TANK CAPACITY 37 n eP
LEUCIUN(3 FACILITY.(cy'
(s ize)/zA
NO, OP BEDROOMS PRIVATE WEL'
. . I- OR WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMP[ LAp4CE ISSUED;
VARIANCE CRANTEID: yes
to A
x.7o
leg -7-oA
q 2
P
--74"I
Al 0A
�-l- :S� � i s'��.�` - l� a #a�♦t �, ��/y��y,�� t �. t�'r �rt�' '�i'/'!i I Ct�'+ �ti�. '.
� Ar+•�i... �l� ��:� r�r�,ys,��� '��`�`r ?�\� ��� .'1',/�'��� a�.i + .t -�$ t-,�"f� •R� I.+ }�,
+,:� :.�t+'*Y z� •��' �r.�'� �� � i"t *.i.f'#t 4�4� �,��c�et"�'.'f:�l� X' ,dr.,�� ,y .
� tr" $d it �'„�' °'� �i " ' Y •� ,�..��'{,a,�,.. ;`�,PF ,?
.�� �„ .,,�• ��. � iy�AN.
�
�'�`.,`ic:
1{ q°^� A��1 } ,- � �. ._vt is } � >I.3 p �. ��. � '� o +'n� ;��.d r i •, e�
s
,4i 34 ♦ �� ,., ,,� - 1+�,,(N 6�8 r�rt•� t"�'' s��" ;. -�•a �� _ _ E
`; ��.L-a�t -v 4r .�a- ��7A,aJ sy v .� e; ,Y.• t�� ^ x ,..r�Z,c,Q a<'.a-� t�•,� 1.. }� _. �t' yr y't ht�i,.,."Y�"r� :.i ti' �� 4 F 'I�'�3 � _ �� '� v.�, r.� .?
.p"•,�.;K; ''' t#y m f 4 �r a F <. ; _ .. � t �" .e Mom;:
'ply R��A �y^'i. '^`�' l e'1'' � �i' �' .�p :'f• � j.. .t' }= .l. �.`A`•�Yx,�a-t�j -- - �;
.71
r a�." t LJ� a ..<"• ; ear �'�"1 �� � `�'�.1
e
4 x
� �x A� ,..','Y r {Yt''•{� �sty �` ;*�� ' �ti 1 _�t ��. m� NY ���-`,t��4
� _ v + � .; ✓�fr '37�c � � T �^'1 p:� '�y� >'4l• y�fr.
MW?-�
1: Ri4.5 �o+l. M•. 7i ��I
� _ - �iti 3���� � >�+i. ifs "� ��/°,i��tr. i. ���''�'t-�` _.„F•`
-� w # � ♦r� � �i A /� , I � {'�" 1; �f�/'{yam '°.���`
•� � � A *�',' tt.1 � 'T 4 i�"dS'9Yl p��l�S,���i� ��[�' w+T
ss �c ft' ♦ uz�9
1, (�;l)' ✓��i r�'k S ��s {?� •!- 4. Ix
S"l \
a
•�^ � � � 4 Y t �.. �Y t I>• (��1`�� 4./ � � ply+.� � Y } ���E,'.}.k
is x /n li�
'`. ?�,++F:�'`{` i,� 3"17�• f,a �'+`,' i�, ", 1• �` 1�?� "t.yR'}, g\ k.r�
ACI
J> � 4�� ,f{�y44� ��R �. �' 'w "f 4 r 4}�, �Xlkz.���srti�.• q } i�F,_�fy� ''r
t
No. k,9Fee �,zo�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y
Zippricatiou for Migoal bpgtem Cou5tructiou Perron
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
e Location Address or Lot No..��1L13v� fp Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel / 1 j 0;
Installer's Name,Address,and Tel.No. esigner's Name,Address and
__Tel.�No.` ' /y
7y,�_Nst_�t_
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature f Repairs or Alterations(Answer when applicable) ZA ✓i-eeL�
iv 2AX
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed lo Date cam'
Application Approved by �A ate
Application Disapproved by: Date
for the following reasons
1
Permit No. Date Issued
- � �_�%"� may►.,..
No. Fee
e d in c omputer: .
:=
THE'COMMONWEALTH OF MASSACHUSETTS Entere
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
s zz
{ Zippricatiott fo Mfgpogar 6!6tem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
a
Location Addressor Lot No. �%�a ` �j Owner's Name,Address,and Tel.No.
.,+i
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. esigner's Name,Address and Tel.No. r
�-y) 2
L-*L2
9
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures ti
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
r Nature of Repairs or Alterations(Answer when applicable)
11
—iz-
i — i '�,9i
�• - _-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. ,
Signed _ 1' /) Date Jg- a-k
Application Approved by - ,� v f� 1�/ ate ,
Application Disapproved by: ' .tom a v aj E' Date
for the following reasons -
Permit No. Date Issued
Co THE COMMONWEALTH OF MASSACHUSETTS
!� BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( V'_) Upgraded ( )
Abandoned( )by r ,�y,s �,q.►.er
�� -
at 4A —1-4--- -f has been const cted in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �' dated
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system w/ ill action as designed.
Date ► / , �1 Inspector�l.
.. No. -- —— _-- -"--_—�--------------,:--.--. Fee _-
\ THE COMMONWEALTH OF MASSACHUSETTS "
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
=igpo.5al *p.5tem Construction Permit
Permission is hereby granted to Construct ( ) Repair O Upgrade ( ) Abandon'( )
System located at
,o /
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construc`on m "st be completed within three years of the date of this pe
Date ) ✓ Approved by
r � Y
1
11/04/2012 16:50 5083750304 LISA PAGE 03
C.,o,mnlonwealth of Massachusetts
:Title 5 ;Official lnspe.ction Form
Subeurtacs Sewage.Disposal Form.-Not for Voluntary Assessments
4352 Route 6A.-Acworth Inn^jMaE
Nopeny Addrtss __.
Lisa Callahan
Ovmcr infurmrnion -_..,._._....,. _._.— ..._.,__._._—.....__.
is required fur Uwner's None
every pqo. Barnstable MA 02530 i3/15/12
Ciivll'u►al _ Stale Zip Code Date of Insipeclion
.D. System YniOrmatiOp (ct•oc.j ....._ ... _... ._.._.._—- -----.._...----_ _......_........_...............
Septic Wank (cont.)
38" .
Distance from top of sludge to bottom of outlet tee or baffle -`-
Scum thickness -- -------._......:......
Distance from top of scum to top of outlet tee or baffle 6-1___... . _.._............ ...... ........._._._.... ... .
Distance front bottom of scum to bottom of outlet tee or.baffle 14_'
Mow were dimensions determined? Tape Measure, Sludge Judge,
Probe
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invest, evidence of leakage, etc.):
Pumping not reccomended at time of insppclion. Liquid level as related to the outlet invert is at a
normal operating height. No evidence of backup or leakage encountered while conducting the
Inspection on the septic tank. PVC Inlet tee is in good condition and !unctioning as intc-nded. Precast
outlet tee cracked as could result in solids carryover. Conditional pass based on replacement of outlet
tee with PVC tee and_ap baffle.
Grease Trap(locate on site plan):
f 1 Depth below grade: f�f....._._..._...__..._-..:....._-- ._.. ..,-
i
Material of construction:
El ❑ metal �]f bergless ❑ polyethylene ❑other(explain):
Dimensions: _.._..._,__.�__._........_..... - - ---
Scum thickness ---=..._.._,.._T.._.....__---__..,_.._..__....._.._
Distance from top of scum to top of obtloi tee or baffle
Distance'frum bottom of scum to bottom of outlet too or baffle
Date of last pumping: uau---- -.........-................
._.,..._. ......_.._..
Tide i wiie;ei bup.Wlon roam suomani o sewose oiipul Spin;•page 10 pr 17
11/04/2012 16:50 5083750304 LISA:' 4 PAGE 04
j Owv� W`�✓
3
A
2
S`
s
t5w•003, 'I81eSOfficWUM%aw Fore.Svbmftee&ValePIWO663System•YM 1SoY17
11/04/2012 16:50 5083750304 LISA PAGE 05
TO" OP 114RNSTABLE'
3l3WAGE
VILLA.CE Y
ASSESSOR'S W.AP 0 LOT /- 33��
INSTALLER'S NAME Cc PHOtjE NO, . �e
SEPTIC TANK CAPACITY Z csAll
p, •c
`'' L$ACHdldO F'AGILfTY:(C � • '��� •��°�'�'f:, .
NO. UA
Eb
ROOM5 PR.IYATE WELL pR P(7.H'l;lC WATER
BUILDER OR ow?gEf7µ_Jw,,.. � I ✓
OATS PER-WIT ISSUED:
DATE COMp{,LANCE ISSUE[); �r
R[ANC E C12AlJT$D; ' ..
• i
IB A 1Iao
1_
p-A /
LAN—
,.j
11%04/2012 16:50 5083750304 LISA PAGE 02
B-E'NNE1"-j- ENV1.•R0N.MEN7"A,,L ASSOCIATES, INCH.
U(Jf.:NSFD SITE PROFESSIONALS,ENVIRONMEi\TAI.SCIENTJIgTS,GEOLOGISTS,r.46INElrl(S
(SU8)8'I6-1706
1573 Main Street,Jl':U.Sox 1743 fax(508)896-5109
Brewster,4 A 02631
LETTER OF TRANSMITTAL
DATE: JOB NUMBER:
i y h+an►a;M.Kean,Director I �R/22/12 +'_J F)J'L A l 1 I OsAS'
L _
eurbstable ilralth nupartnacnt
200 Main Sti•ret REGARDING::
�Hyannis,MA 02601
SF,PTIC SYS1*E-%4 RE-1NS'PE.CTlQN
TITLE V REAL ESTATE TRANSFER RFQVIRCMENTS
(.___�..�.— ._....._...... .._ .....__.,.__. ..T�..T_.- Request for Board of Henith Hearing
StIOPPING METHOD:
... -„-._._._...--.—•-- •-• Acworth inn(Lisa(•'altr+han)
�x fZekular Mail "� •J^_ Pick f'p L7 4352 Routo 6A i
Barnstable,MA
IC:iurity Mail [_; )•land Dcliver D i
i D
Ih;�•prtys Mail
Ic'ertified Mail Green Card/113.
COPIES S Y DATE DESCRIPTION
�. ._.._�_...... ..._k....._R;7,1;12..._-I :i11e51?tTci®1lnspection NMI
- ---
j .14352 Route 6A-Acworth frill (IV
iap 351,Parcel 03v) ;
2ieptic 1tlspectiou Filing Fee check no.4766(S25.00) 1
1 8/1512 I septic Inspection Photographic Documentation
For review and.w)rnnient: [l For approval fJ As requested: j] For Your use; .a
�C)n•at'Mr.'�,�-Kesr+,^--.._.._...-....,._..... 1
Per prior c;)mrr:unicatirns with your:)`five August 13,20)2,plesae find enclosed the Tile 5 Rr.-inspection for the Acwoa•th lun j ir+ pectii;n +as.conducted as pre,c rih;d by the Barnstable Board of Health a1 our meeting in December 2011 as,;onsiswrit with the 4130�
Pulic)-420i 0-01%n•here;n the 1 t,iling systom is Jaiet docu;nentod by twu indepenocot Inspections to have Pussrd. 'this is the ce�ur 1 F,uch
septic ir+ypcetion more Than.six(61 months apart to find that the sy•textt is not in failure The septic system is found to l;onAilion ly Noss as
rub)e��'io_nzim,r repairs tr rr,. lace.the septic tank concrete outlet lee with a PVC tee and to replace septic tank outlet and d'box cokc+'> l
t ii4e inclidr- phur.+grai!hs IJom+. c tity of e most recent i spec ion•to uw D •
oient � irigs.
f' Please uoiiliim with this office that we brave been placed on'rha 13330H agenda for the Septemher 18,2•U12.puhtic hearing Should you huve
t hny.ytii 9tiaris or raced ad�;itii^n.�l i tl'ormation,pit se contact m4 directly at my of iu.Thank you.
oe• Lisa C:e lahan,At:•.ww•th Inn(inspection and photographs only)
F'Rom:- `r)a,-id C. 64 f)vjetr,R.S -
if metric+urea are nor ea noDad,kindty nunfy of ac once
I
of � Town of Barnstable Barnstable
SHE�
Regulatory Services AO-America Citrr Department 1
BARN STABLE, D
"Ass. Public Health Division
ArFb✓a 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7006 0810 0000 6703`
September 4,2012
Acworth Inn
Attn: Ms Lisa Callahan
4352 Main St/Rte 6A
Barnstable, MA 02530
ORDER TO COMPLY WITH STATE•ENVIRONMENTAL CODE, TITLE 5
The septic system located at 4352 Main St/Rte 6A, Barnstable,MA was last inspected
on August 8, 2012 by David C. Bennett, RS, a certified septic inspector for the State of
Massachusetts. }
The inspection of the septic system showed that the system "Conditionally Passes" `
under the guidelines of 1995 TITLE 5 (310 CMR 4 5.00) due to the following:
• Cover on D-box needs to be replaced
• Precast outlet tee cracked; needs replacement
You are ordered to repair or replace the septic system within two (2) years from the date
you receive this notification.
Failure.to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health -
CERTIFIED MAIL#7006 2150 0002 1041 7767
Documentl
S
Town of Barnstable
s r
a
+ BARNSI'ABLE,
19. Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Junichi Sawayanagi
Paul Canniff,D.M.D.
Wayne Miller,M.D.
November 20, 2012
Mr. Joseph Smith
Bennett Environmental Associates
1573 Main Street _
P.O. Box 1743
Brewster,MA 02631
RE . AcworthInn, S-epticySysteni Inspections T A 351'.039
Dear Mr. Smith,
The order from the Health Agent dated September 27, 2011 to repair a failed septic
system at the Acworth Inn, 4352 Main Street/Route 6A, Barnstable is lifted. You are
granted permission, on behalf of your client, Lisa Callahan, to maintain the use of the
existing septic system with the following condition:
0 The cracked precast outlet tee and the distribution box cover .
shall be replaced within six months.
The septic system originally failed during an inspection conducted by Sean Jones on
September 9, 2011. The `soil and stone surrounding the soil absorption system (S.A.S.)
were saturated' according to Mr. Jones report. However, on November 18,2011, t wo
other certified septic inspectors, Joseph Smith and ChadHathaway, passed' the same
septic system, finding no signs of hydraulic failure in regards to the soil absorption
system. Then on August 21, 2012, David Bennett, R,S. inspected the system and it
"conditionally passed,' finding that the cracked precast outlet tee and distribution box
cover both needed replacement.
Based upon the information presented,the Board is of the opinion that it is unlikely that
this particular septic system will present a source of pollution or present a public health
nuisance to the occupants or to the neighbors in the near future. Therefore, the original
ordjdd Septemb r 27, 2011 is lifted.
Sinyours,
W one M 1 , M.D., Chairman
Q:\4 PFILES cwor[hInnBennettSewerOrderLifted2012.doc
NTINUE
-AUG/SEP'2012
Excerpt from Board of Health Meeting Minutes 1/1012:
I. Title V— Septic Inspection Review:
Joseph Smith, Bennett Environmental Associates,representing <cworth Inn
4352 Route 6A, Barnstable, Map/Parcel 351-039, two new sep =
inspections were done and passed. Original inspection failed on
09/09/2011.
The Board voted to rescind the order to replace the septic system within a year.
No further action is required until Aug/Sep 2012 at which time the Board requires
another septic inspection to be done. If the septic system then passes, the Board
will deem the system as passed.
Mr. Smith may contact Capewide to view the;videotape of the inspection to speed
things along..
• � �nV`r• AS�o e
�a 6� will
f 4 �4;P ge 1 of 1
Crocker, Sharon
_ .. Lip
ti
From: Dave Bennett[dbennett@bennett-ea.com]
Sent: Monday, August 13, 2012 2:14 PM � -
To: McKean, Thomas; Crocker, Sharon.
Cc: acworthinn@comcast.ne - gym•i ;'nit ro@kinlingrover.com
Subject: Septic Re-inspect' of Ackworth Inn
Tom,
Thanks for taking my call today and to provide additional guidance on the Barnstable BOH Septic Re-
Inspection Policy. Please find attached our original communication with your office on this matterWith
the initial re-inspections of the system in September 2011. In the presentation of this these reports to
the Barnstable Board of Health, BEA was advised that a third re-inspection was to be conducted during
peak seasonal use as was the original for verification of condition. Now it is my understanding that the
BBOH policy adopted after our hearing, requires two independent inspections within 6 months which
had formerly been conducted but not accepted as based on seasonal use issues.
As such, I need you to clarify if we can proceed with the re-inspection for this coming Wednesday as
being greater than 6 months from the previous re-inspections as was required at the time of our hearing
as in conflict with the aforementioned policy.
I will personally be doing this re-inspection and need confirmation from you that the initial guidance
from the BOH takes precedence over the policy as would be framed in the minutes of the meeting in
December 2011 . By copy to Sharon, I would ask that the Ackworth Inn Re-Inspection for August 2012
be put on the September 18th agenda as acceptable for overturning the failed inspection by CapeWide
Enterprises in September 2011.
David C. Bennett, RS., CGWP., LSP
President
BENNETT ENVIRONMENTAL ASSOCIATES
1573 Main Street/ P.O. Box 1743
Brewster, MA 02631
508-896-1706
508-896-5109 fax
http://bennett-ea.com
Visit us on Facebook
Bennett Environmental Associates, Inc.
Confidentiality Notice:
This electronic mail message and any attached files contain information intended for the exclusive use
of the individual or entity to whom it was addressed and may contain information that is proprietary,
privileged, confidential and/or exempt from disclosure under applicable law. If you are not the intended
recipient, you are hereby notified that any viewing, copying, disclosure or distribution of this
information may be subject to legal restriction or sanction. Please notify the sender, by electronic mail
or telephone, of any unintended recipients and delete the original message without making any copies.
Go Green! Consider the environment before printing this email.
8/13/2012
Mr. Wilson expects he will have a new plan ready in a couple weeks and will bring
in extra copies for neighbors who are interested in getting a copy at the Health
Division.
The Health Division will also have information about the Microfast System
available.
The Board will conduct a site visit on Monday, February 6, 2012 at 11:30am.
Upon a motion duly made by Mr. Sawayanagi, seconded by Dr. Canniff, the Board
voted to Continue to February 14, 2012 will a revised plan showing an I/A Microfast
System and a new floor plan. (Unanimously, voted in favor.)
B. Robin Wilcox, Sweetser Engineering, representing Daniel and Suzanne
Perini, Trustees, D&S Perini Realty Trust— 58 Holway Drive, West
Barnstable, Map/ Parcel 136-033, 44,500 square feet lot, subdivided in
1971 as Point Hill Realty Trust, requesting multiple setback variances.
The Staff did not have any issues of concern with the plan. The Board was
comfortable with it as well.
Upon a motion duly made by Dr. Miller, seconded by Mr. Sawayanagi, the Board
voted to approve the variances with following conditions: 1) A four-bedroom deed
restriction is recorded at the Barnstable County Registry of Deeds, and 2) a proper
copy of the deed restriction is submitted to the Public Health Division.
III. Title V Septic Inspection Review:
Joseph Smith, Bennett Environmental Associates, representing Acworth Inn
—4352 Route 6A, Barnstable, Map/Parcel 351-039, two new septic
inspections were done and passed. Original inspection failed on
09/09/2011.
Joseph Smith said he passed the system on 11/18/11, saw no reason for failure
and he also reviewed the other report done by Capewide done on 9/9/11 which
failed.
Dr. Canniff asked Mr. Smith whether he thought it may have been hydraulically
overloaded in September due to a possible busy summer usage and possibly had
the opportunity to dry out by November. Mr. Smith said he installed the monitoring
point 8.5 feet below the surface just outside the leaching area and the monitoring
well came up dry. The design is built for 660 gallons/day flow.
Mr. Smith also said the other report doesn't make sense because if there is
hydraulic failure you usually see the D-box full and in the other report, the D-box
was at the invert height which would be zero — no water.
Page 3 of 6 BOH 1/10/12
3.
t' -•:;.
Mr. McKean said the other report had run a camera down the eight laterals and
reported seeing sand and water, the soil saturated.
Mr. Smith mentioned that you would see some water in the laterals due to the
perforations in the pipes.
The owner had two inspections done the same day 11/18/11 by two inspectors
which both passed.' The Board explained that as this type of situation has been
coming up over the last eight months, they normally want a year in between the
two inspections. Mr. Smith had been unaware of this and asked the Board to add
something in writing to the Health's web page to inform the public more. The
Board said that would be done and it specify that it is on a case-by-case basis.
Mr. Smith may also check with Capewide and view the video from them. The two
of them may then come up with the same conclusion, which would then allow the '
owner to know where things stand sooner rather than later as the owner is in the
process of selling the property.
Upon a motion duly made to.Dr. Canniff, seconded by Mr. Sawayanagi, the Board
voted to rescind the request to have the septic system replaced within one year,
and to do another septic inspection during the month of August or September
2012. The applicant is to come back to the Board at the 9/11/2012 meeting with
the outcome. (Unanimously, voted in favor.)
IV. Variance— Food (New):
A. Kathy Murray, owner,Barnstable Market— 3220 Main Street, Barnstable,
Map/Parcel 300-010, grease trap variance, has limited menu and is a small
market.
Board Member Mr. Sawayanagi recused himself and stepped out of the room.
Kathy Murray was present, along with Roger Parsons, Town Engineer.
Barnstable Market proposed to use both the Big Dipper (a grease trap interceptor) and
a 600 pound grease trap known as the Trapzilla which will be outside the building.
There is a smaller one which holds 400 pounds of grease but they decided to go with
the larger one.
Roger Parsons, Town Engineer, said that grease needs to cool down before grease
can separate, therefore, he suggested the Trapzilla.
Kathy Murray said their three restaurants will all be maintained by the same contractor
and the Barnstable Market will begin by being on the same schedule, emptied every
six weeks, until they assess the actual need —which will probably be less frequently.
Page 4 of 6 BOH 1/10/12
J
Page 1 of 2
Crocker, Sharon
From: acworthirx`Earon
et
Sent: Wednesd , 2012 7.47 AM
To: Crocker,
Subject: Meeting agenda
Hi Sharon,
As a follow up to earlier emails from Bennett Environmental, and the January 2012 BOH
meeting, he Acworth Inn (4352 main, Cummaquid) is on the agenda for the 9/18
meeting to hopefully resolve the septic issue. I am not sure if it's possible, but if so, I
would like to request that we be the last item on the agenda, or a least one of the latest
ones on the schedule that day. I am a teacher in the town of Barnstable and I will be
coming from my teaching job, and it would be very helpful if I our appearance was as
late in the agenda as possible, to avoid a conflict with school.
Anything you can do to help would be greatly appreciated.
Thank you,,
Lisa Callahan
V �A
as�.v. A, �`�
From: "Dave Bennett" <dbennett@bennett-ea.com>
To: "Thomas McKean" <Thomas.McKean@town.barnstable.ma.us>, "sharon crocker"
<sharon.crocker@town.barnstable.ma.us>
Cc: acworthinn@comcast.net, "Joe Smith" <jsmith@bennett-ea.com>,
nsantoro@kinlingrover.com
Sent: Monday, August 13, 2012 2:14:03 PM
Subject: Septic Re-inspection of Ackworth Inn
Tom,
Thanks for taking my call today and to provide additional guidance on the Barnstable BOH Septic Re-
Inspection Policy. Please find attached our original communication with your office on this matter with
the initial re-inspections of the system in September 2011. In the presentation of this these reports to
the Barnstable Board of Health, BEA was advised that a third re-inspection was to be conducted during
peak seasonal use as was the original for verification of condition. Now it is my understanding that the
BBOH policy adopted after our hearing, requires two independent inspections within 6 months which
had formerly been conducted but not accepted as,based on seasonal use issues.
As such, I need you toclarify if we can proceed with the re-inspection for this coming Wednesday as
being greater than 6 months from the previous re-inspections as was required at the time of our hearing
as in conflict with the aforementioned policy.
I will personally be doing this re-inspection and need confirmation from you that the initial guidance
from the BOH takes precedence over the policy as would be framed in the minutes of the meeting in
December 2011 . By copy to Sharon, I would ask that the Ackworth Inn Re-Inspection for August 2012
9/11/2012 -
Y
i
` . Page 2 of 2
be put on the September 18th agenda as acceptable for overturning the failed inspection by CapeWide
Enterprises in September 2011.
David C. Bennett, RS."°CGWP., LSP
President
BENNETT ENVIRONMENTAL ASSOCIATES
1573 Main Street/ P.O. Box 1743
Brewster, MA 02631
508-896-1706
S08-896-5109 fax
http://bennett-ea.com
Visit us on Facebook
Bennett Environmental Associates, Inc.
Confidentiality Notice:
This electronic mail message and any attached files contain information intended for the exclusive use of the
individual or entity to whom it was addressed and may contain information that is proprietary, privileged,
confidential and/or exempt from disclosure under applicable law. If you are not the intended recipient, you are
hereby notified that any viewing, copying, disclosure or distribution of this information may be subject to legal
restriction or sanction-. Please notify the sender, by electronic mail or telephone, of any unintended recipients
and delete the original message without making any copies. ,
Go Green! Consider the environment before printing this email.
9/11/2012
Message Page 1 of 1
Crocker, Sharon
From: McKean, T s on e of Health
Sent: Monda , November 07, 2011 1:52 AM
To: David Benne
Subject: RE: BOH Appeal of Septic Inspection Report-4352 Route 6A(Ackworth Inn)
Please be advised that, in the Town of Barnstable the Board of Health requires two passing inspection
reports, from two different inspectors,to overturn a failed inspection report.
-----Original Message-----
From: David Bennett [mailto:dbennett@bennett-ea.com]
Sent: Monday, November 07, 2011 10:48 AM
To: Health
Cc: acworthinn@ackworthinn.com; nsantoro@kinlingrover.com
Subject: BOH Appeal of Septic Inspection Report-4352 Route 6A(Ackworth Inn)
Dear Mr. McKeon,
Pursuant to our conversation regarding the Failed Septic Inspection by Capewide Enterprises
(Sean Jones SI#6848)as submitted to your department on September 22, 2011, Bennett
Environmental has been retained by the owner to review such documents and undertake
additional field work to investigate the claim of water in pipes within the leach field as the basis
for Septic Inspection Failure. In our review of the Septic Inspection Report submitted,the Section
B Certification (D)System Failure Criteria,we note that the no affirmative answer was given to
the System Failure criteria wherein septic system hydraulic failure(overloaded or clogged SAS)
was not noted in the static water levels within the septic tank or D'Box. To qualify these findings,
BEA conducted an independent inspection of the D'Box and found liquid levels at the outlet
inverts with no evidence of higher standing water levels although the condition of the D'Box was
noted as significantly deteriorated. To further qualify any ponding or-failure of the SAS, BEA
installed a piezometer in the vicinity of the SAS and found no standing water present.
We have in fairness requested a copy of the video used as part of the septic inspection by
Capewide to evaluate the findings leading to the determination of SAS failure. At the time of this
writing, no tape has been produced. As such,with your permission BEA would like to complete
another full inspection of the septic system to submit to the Barnstable Health Department for
your reconsideration of the Title V Septic System Condition and to seek a hearing with the Board
of Health to appeal the findings of the first inspection report as may be appropriate.
Please reply or give me a call if in fact the Board of Health will accept a second Septic Inspection
report for reconsideration. Thank you for your time and consideration of this matter.
David C. Bennett,RS., CGWP.,LSP
Principal
BENNETT ENVIRONMENTAL ASSOCIATES
1573 Main Street/P.O. Box 1743
Brewster,MA 02631
508-896-1706
508-896-5109 fax
h_ttp://benn ett-ea:com
Confidentiality Notice:
This electronic mail message and any attached files contain information intended for the exclusive use of the individual or entity to
whom it was addressed and may contain information that is proprietary,privileged,confidential and/or exempt from disclosure under
applicable law. If you are not the intended recipient,you are hereby notified that any viewing,copying,disclosure or distribution of this
information may be subject to legal restriction or sanction. Please notify the sender,by electronic mail or telephone,of any unintended
recipients and delete the original message without making any copies.
Go Green! Consider the environment before printing this email.
9/11/2012
�t„Er Town of Barnstable Barnstable
ti
Board of Health
MA sag 200 Main Street, Hyannis MA 02601
s63q. �0
RFD p�p`l A
2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.D.
Junichi Sawayanagi
BOARD OF HEALTH MEETING RESULTS
Tuesday, January 10, 2012 at 3:00 PM
Town Hall, Hearing Room, 2ND Floor
367 Main Street, Hyannis, MA
I. Hearing — Housing / Septic (Cont):
POSTPONED A. Lili Seely, owner— 33 Candlewick Lane, Hyannis —
UNTIL FEB 14 housing and septic issue (continued from Dec 2011).
2012
POSTPONED B. Kenneth Carey, owner—439 (a.k.a. 441) South Main
UNTIL FEB. 14 Street, Centerville,3 units, housing violations
2012 (continued from Dec 2011).
II. Variances — Septic (New):
A. Stephen Wilson, Baxter Nye Engineering, representing David Brito, P&S
Agreement with owners — 31 and 43 Church Hill Road, Centerville,
Map/Parcel 207-138 and 207-139, total two lots is 32,045 square feet,
multiple variances.
Many spoke of their concerns with the property.
The Board will conduct a site visit on Monday, February 6, 2012 at 11:30am and
will visit the property if it rains before the next meeting.
The Board voted to continue to February 14, 2012 and will review a revised plan
which should be available in a couple weeks,,showing an I/A Microfast System and
a new floor plan once it is available.
Mr. Wilson will bring in extra copies of the plan, once completed, for the interested
public. The Health Division will also have information about the Microfast System
available.
Page I of 3 BOH 1/10/12
B. Robin Wilcox, Sweetser Engineering, representing Daniel and Suzanne
Penni, Trustees, D&S Penni Realty Trust— 58 Holway Drive, West
Barnstable, Map/ Parcel 136-033, 44,500 square feet lot, subdivided in
1971 as Point Hill Realty Trust, requesting multiple setback variances.
The Board voted to approve the variances with following conditions: 1) A four-
bedroom deed restriction is recorded at the Barnstable County Registry of Deeds,
and 2) a proper copy of the deed restriction is submitted to the Public Health
Division.
III. Title V— Septic Inspection Review:
Joseph Smith, Bennett Environmental Associates, representing Acworth Inn
—4352 Route 6A, Barnstable, Map/Parcel 351-039, two new septic
inspections were done and passed. Original inspection failed on
09/09/2011.
The Board voted to rescind the order to replace the septic system within a year.
No further action is required until Aug/Sep 2012 at which time the Board requires
another septic inspection to be done.. If the septic system then passes, the Board
will deem the system as passed.
Mr. Smith may contact Capewide to view the videotape of the inspection to speed
things along.
IV. Variance — Food (New):
A. Kathy Murray, owner, Barnstable Market— 3220 Main Street, Barnstable,
Map/Parcel 300-010, grease trap variance, has limited menu and is a small
market.
The Board voted to approve the grease trap variance with the condition that Roger
Parsons, Town Engineer, will take a look at the grease situation for the first two
months.,
B. Attorney David Lawler representing Mary Phelps, owner of Earthly Delights
— 15 West Bay Road, Osterville, Map/Parcel 141-016, request for two
variances: toilet facility and outdoor dining.
The Board voted to approve a toilet facility variance to allow the 12 outdoor seats.
C. Jason Berg, Panera Bread — 790 lyannough Rd, Hyannis, Map/Parcel
311-092, request for toilet facilities variance with additional seating.
Page 2 of 3 BOH 1/10/12
r ,
Alternatives were discussed. Panera Bread may return to the Board with a revised
proposal.
Currently, the Board DENIED the request of eliminating two employee bathrooms
for additional seating.
V. Septic Installer (New):
A. Daniel Duprez, Littleton, MA
The Board voted to approve Daniel Duprez for a septic installer.
B. Craig Condinho, Marstons Mills, MA
The Board voted to approve Craig Condinho,for a septic installer.
VI. Policy/ Regulation:
POSTPONED TO FEB 14, 2012 A. Signage "Wording" and Beach
Designations.
B. Ban on Pharmacy Tobacco Sales.
There are 6-7 towns which have recently put into effect a similar ban.
The staff is opposed to the ban. They feel it interferes with equal rights of
commerce.
The Board members feel it is necessary. The State is also looking into passing a
state-wide policy. Mr. McKean will research and see how close the State is to
passing the policy. In the meantime, Dr. Miller will have the Legal Department
write up a regulation to be reviewed.
Page 3 of 3 BOH 1/10/12
Message Page 1 of 2
McKean, Thomas
From: McKean,-Thomas on behalf of Health
Sent: Friday, December 16, 2011 10:04 AM
To: 'Joe Smith'
Cc: Crocker, Sharon
Subject: RE: 4352 Route 6A Title V re-inspections.
Good Morning,
I received all three septic system inspection reports; the first dated 9/9/2011 showing that the system
failed and second and third both dated 11/18/11 showing the system passed.
I will forward this to the Board of Health for a public hearing on Tuesday January 10, 2012 at 3:00 p.m.
at the Town Hall, second floor Hearing Room.
Sincerely,
Thomas McKean
-----Original Message-----
From: Joe Smith [mailto:jsmith@bennett-ea.com]
Sent: Wednesday, December 14, 2011 3:29 PM
To: Health
Cc: acworthinn@acworthinn.com; David Bennett
Subject: 4352 Route 6A Title V re-inspections.
Mr. McKean,
I tried to get in touch with you earlier this week and left a message for you as I had a question in
regards to the status of the re-inspections of the Acworth Inn located at 4352 Route 6A in
Barnstable. I was wondering if there was going to be a hearing on the title V inspections or if the
two re-inspections sufficed for the Town of Barnstable to deem the system a passing system. Can
you please advise me as to what the status is and or if any other actions will be necessary so that
can forward any information on to our client.
Thank you,
Joseph R. Smith
Joseph R. Smith, WWTO
Operator
BENNETT ENVIRONMENTAL ASSOCIATES, INC.
1573 Main Street/P.O. Box 1743
Brewster, MA 02631
508-896-1706
508-896-5109 fax
htti)://bermett-ea.com
Confidentiality Notice:
This electronic mail message and any attached files contain information intended for the exclusive use of the individual or entity to
whom it was addressed and may contain information that is proprietary,privileged,confidential and/or exempt from disclosure under
12/16/2011
.r• 4}�.c t; .+ fig;Y 3�-
Lrt I• / • • • • • pv-
ti
Ul
Ln
Postage, $ H
r Certified Fee !y
O Po tr ark Y
O Retum Reoelpt Fee c: Here N
O rs(Endoement Required) cc
O ResMated t liver Fee
(EndorsemeM Required) O
O Total Postage&Fees
a, Acworth Inn
r ; ATTN: Ms Lisa Callahan
4352 Main Street/Rte 6A--'
Barnstable, MA 02630 -
Certified Mail Provides:
In Amailing receipt
n A unique identifier for your mailpiece ` -
o A record of delivery kept by the Postal Service for two years -
Important Reminders:
0 Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
o Certified Mail Is not available for any class of international mail.
m NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For I'I
valuables,please consider Insured or Registered Mail.
a For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the li
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPSe postmark on your Certified Mail receipt,is,
required.
a For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
m If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt Is not needed,detach and affix label with postage and mail.
IMPORTANT-Save this receipt and present it when making an inquiry.
PS Forrn 3800,August 2006(Reverse)PSN 7530-02-000-9047
EN DER::COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signet
item 4 if Restricted Delivery is desired. X ❑Agent
® 'Print your name and address on the reverse ` ❑Addressee
so that we can return the cans to you. B. iv d b Pr1n a e of
De iv
a Attach this card to the back of the mailpiece, �G� �k ry
or on the front if space permits.
1. Article Addressed to: D. Is delivery address different from ite 1? ❑Yes
If YES,enter delivery address below: ❑No
Acworth Inn
ATTN: Ms Lisa Callahan rt
4352 Main Street/Rte`6A r
3. Service Type
Barnstabte, MA r02630 ❑wed Mall ®Upress Mall
❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number , 7 011101+i7 0'j 0 0 0`1? 4525 5 2 9 7
(Transfer from service labeQ' i j i i i i r r i 1 1•_ ..r � }s o f r:
rn Receip-t r'' 102595-02-M-1540,
d'-.x.YtntWt�,
UNITED STA1*" TX$OWERA.
Ss: Feg,tPafd
• Sender: Please print your name, address, and ZIP+4 in this box •
Town of Barnstable
'. Public Health Division
200 Main Street w l
Hyannis,MA 02601 I
y� �;.,,... 1��I11i!lf�l'�11�1!!!!l17�l1tLl�liil-11.t!lttlll��!ltillltlfl�l�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 4352 Rt 6a(Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector.
key.
Capewide Enterprises
4:1
Company Name
153 Commercial St.
Company Address
Mashpee Ma. 02649
Cityrrown b State Zip Code
508-477-9877 SI 4522
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 CHAR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
9/9/2011
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of they DEP. The original should be sent to the system owner
and copies sent to the huger;--if-applicab1C-,^d the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection,doets pot address how the system will perform in the future under
the same or differen coWditienst of use ,tf
e
ll
01 -OA
t5ins-11110 Title 5 Offidal Inspection Form:Subsurfe:r..p Di sal System-P ge 1 of
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
< 4352 Rt 6a (Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B1 System Conditionally Passes:
Y
❑ 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•11/10 Title 5 Official Inspection Form:Subsurface
Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a (Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityfrown State, Zip Code Date of Inspection
B. Certification (cont.)
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
of 114E rod
Town of Barnstable Barnstable
yvP tio, AHmmicaCity
I: . Regulatory Services Department 1
4' BARNSCABLE,
9�A 639. ,�� Public Health Division
re0 Mai"' 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7011 0470 0001 4525 5297
September 27, 2011
Acworth Inn
ATTN: Ms Lisa Callahan
4352 Main St/Rte 6A ,
Barnstable, MA 02530
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 4352 Main St/Rte 6A,Barnstable, MA was last inspected
on 9/9/2011,by Sean M. Jones, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Inspection showed standing water in D-Box, indicating that the soil and stone
surrounding the SAS is saturated and unable to leach.
Dwelling has 6 bedrooms and is commercial, this septic tank( 1500 gal) is considered
inadequate and should be replaced with a larger tank.
You are ordered to repair or replace the septic system within one (1) year from the
Date you receive this notification.
Failure to repair/replace the septic system within the deadline period may result in
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
s cKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\TEMPLATEI.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a_(Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ 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
❑ ® 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
• ' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a (Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityfrown 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.
❑ ® Anportion f y o a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area-IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary ryAssessments
4352 Rt 6a(Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is Barnstable M 02530 9/9/2011 ae a
required for every B II
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as NIA)
® ❑ 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): 6 Number of bedrooms(actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 gpd
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a (Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: unknown
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)):
Detail:
2009= 114,000 total= 312 gpd 2010= 99,000 total=271 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
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-11f10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a (Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Citylrown 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
A
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a(Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System repaired 1992 per town records
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: 1 feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade: .5
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: 1500 gallons
5„
Sludge depth:
tsins•11/1 o Title 5 Official inspection Forth:subsurface sewage Disposal system-Page 9 of 17
c
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y( 4352 Rt 6a(Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
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 3.5'
„
Scum thickness 2
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers and took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
System consists of a 1500 gallon septic, dwelling has 6 bedrooms and is commercial, this septic tank
is considered inadequate and should be replaced with a larger tank.
C
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•11110 Tide 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
. Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a (Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityrrown State Zip Code. Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a (Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page_ Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Water level was even with all 8 outlets.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5. Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a(Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1w8laterals14x48x6
❑ 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.):
Video camera run from d-box down all 8 laterals showed standing water indicating that the soil and
stone surrounding the s.a.s. is saturated and unable to leach resulting in a failing Title V Septic
Inspection.
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•11/10 Tifie 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a(Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
}
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'( 4352 Rt 6a(Acworth Inn)
Property Address
Lisa Callahan
Owner Owners Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rt 6a(Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's!dame
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
, ❑ Obtained from
system design plans on record
y 9
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:
System fails inspection, groundwater elevation was not established
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 4352 Rt 6a(Acworth Inn)
Property Address
Lisa Callahan
Owner Owner's Name
information is required for every Barnstable Ma 02530 9/9/2011
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System-Page 17 of 17
TO" OF PARNSTABLE I
SEWAGE
VILLAGE �..
ASSESSOR'S iH A P LOT
INSTALLER'S NA14E PHONE y
i
SEPTIC' TIC TANK CAPACITY � J` ��:�.j: h.�;
r LEACHING FACILITY:{type
NO. OF 13EDR.00I4fS
PRIVATE WELL OR PUBC`1C WATER
BUILDER OR Ow
N E R �i4.a-•sax___ p F !.� �-s'i o.�....� ,
CRATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:--- - _ _�,
VARIANCE CRANTED: yes '"� �✓
r
r- 13
K X-1
® Yr A
a
/37"
I i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, /}
use only the tab 1. Inspector:
key to move your
cursor-do not Chad Hathaway
use the return Name of Inspector
key.
H.P.S.
c Company Name
1 Warwick way
Alf Company Address
Mashpee Ma 02649
City/Town State Zip Code
1 774 274 2581 12866
Telephone Number License Number
B. Certification
f I certify that I have personally inspected the sewage disposal system at this address and that the
`1 -- 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 16.340 of
- Title 5(310 CMR 15.000).The system:
t Ei SPasses ❑ Conditionally Passes ❑ Fails
i
❑ Needs Further Evaluation by the Local Approving Authority
1/18/11
(s pector's Signature Date
The system inspector shall submit a copy o-tt"is inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of co��rppfeting this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or grater, 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.
0 3N
155ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage i posal System•Page 1 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) j
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:
tank in good cond. DBox in working cond. no signs of failure inspected monituring well that was
installed in leach bed found no standing water. Dug down at edge of field stone was clean and no
signs 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
4 Commonwealth of Massachusetts
uW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma -02637 11/18/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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
t5iru•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
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 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
❑ ® 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M r 4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply -
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
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): 6 Number of bedrooms(actual): 6
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 660
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
tee` 4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. Cityrrown State Zip•Code Date of Inspection
D. System Information
Description:
Number of current residents: 1 full time+
B and B
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 291 gpd
9 ( Y 9 (gpd)):
Detail:
2009 114,000 2010 99,000
Sump pump? ® Yes ❑ No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: B and B
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
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:
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
L
Commonwealth of Massachusetts
up
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
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:
1992 As built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5'
p g feet
Material of construction:
❑ cast iron ®40 PVC ❑other :ex lain
( P )
Distance from private water supply well or suction line: 20+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
811
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: .
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
511
Sludge depth:
t5ins•09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
g 4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. Citylrown State Zip Code Date of Inspection
D. System Information (coat.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
35"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined?
sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade: 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•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09= Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box equalizers in box water flows to outlets evenly no signs of past or preasent failure
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
checked monitering well was dry and dug down at end of system stone was clean and dry
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
8)14'L 4'W 6" D
❑ 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.):
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-09/08 The 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. CWTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09f08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is
required for every Barnstable Ma 02637 11/18/11
page. Cityrrown 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
oA
1 a�.5- B .
p� ),`4 .0
f ho hiW> 3 g
mw
t5ins-0901 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: N/A -
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: 1992
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:
no GW test logs
Before filingthis Inspection Report, lease see Report Completeness Checklist on next page.
p P P
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4352 Rte 6A
Property Address
Lisa Callahan Acworth Inn
Owner Owner's Name
information is required for every Barnstable Ma 02637 11/18/11
page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form :Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351,Parcel 039)
Property Address
Lisa Callahan
Owner information Owner's Name
is required"for
every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see
completeness checklist at the end of the form.
Important:when filling out forms on A. General Information
the computer,use
only the tab key to 1. Inspector:
move your cursor-
do not use the Joseph R. Smith
return key. Name of Inspector
d� Bennett Environmental Asscoiates, Inc.
Company Name
1573 Main Street/P. O. Box 1743
Company Address
Brewster MA 02631
City/Town State Zip Code
(508)896-1706 S14994
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
,r, h
® Passes ❑ Conditionally Passes ❑ Fails=
❑ Needs Further Evaluation by the Local Approving Authority
Th
11-18-11 x �'
pector's Signature Date t?J
The system inspector shall submit a copy of this inspection report to the Approving Authori)yy(Boar
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.
�-Aj D
!-
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewa Disposal System•Page I of 17
Commonwealth of Massachusetts
4 m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form 6.Not for Voluntary Assessments
M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
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 working condition and is functioning as intended. None of the failure criteria described in
310 CMR 15.303 or in 310 CMR 15.304 existed at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes',"no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally_
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments_
wM 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
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 Y day flow
t5ins•09/08 Title S.Official Inspection Fong:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
S. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
.provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 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.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 4352 Route 6A-Acworth Inn[Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
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)]
A System Information
Residential Flow Conditions:
Number of bedrooms (design): 6 Number of bedrooms(actual): 6
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 660
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 0391
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11 .
City/Town State Zip Code Date of Inspection
D. System Information
Description:
Septic System that serves bed and breakfast is comprised of a 1,500 gallon septic tank, d-box, and a
14'x 48'x 0.5' leaching field.
Number of current residents:
not known
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See Details
9 ( Y 9 (9P ))�
Detail:
2009- 114,000 gallons =312 GPD ; 2010-99,000 gallons =271 GPD
Sump pump? ® Yes ❑ No
Last date of occupancy: Currently in use
Date
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? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 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_
,. 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every Page. Barnstable MA 02530 11-18-11
City/Town State Zip Code. Date of Inspection
A System Information (Pont.)
Last date of occupancy/use: currently in use
Date
Other(describe below):
Sump pump in the basement is used for water intrusion through foundation from surrounding
landscapes that pitch towards the foundation itself, and due to poorly draining soils
surrounding the foundation as well. Discharge to ground surface outside building. Not
connected to septic system.
General Information
Pumping Records:
Source of information: Town of Barnstable Board of Health
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gapons
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
A System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System upgraded with BOH approval in 1992- per site and sewage plan with a revision date of 4-21-
1992. Plans and permits on file with town BOH.
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: 2 feeet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Properly vented. No evidence of leakage of joints or backup into building encountered while
inspecting building sewer line.
Septic Tank(locate on site plan):
0.5'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
1,500 gallon septic tank with concrete inlet and outlet tees.
If tank is metal, list age:
Years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1 0'6"L x 5'8"W x 5'8"H
Sludge depth:
5"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form- Not for Voluntary Assessments
M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
A System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
36"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle
6"
1411
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Tape Measure„Sludge Judge,
Probe
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not reccomended at time of inspection. Both inlet and outlet tees are functioning properly.
Liquid level as related to the outlet invert is at a normal operating height. No evidence of backup or
leakage encountered while conducting the inspection on the septic tank.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
A System Information (cont:)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page I I of 17
f
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 4352 Route 6A-Acworth Inn [Map 351,Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 11-18-11
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 Effluent at outlet invert is normal
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is level and distributing effluent to the leaching field appropriately. Some evidence of solids
carryover present in the D-box, no high water stain line present on the interior face of the D-box
present. No evidence of leakage into or out of d-box encountered while conducting inspection of the
D-box. Static effluent level in D-box was at a normal operating height and the effluent evel was even
with all of the outlet inverts. Corrosion of concrete below water line noted.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Font Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,.•'•L 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
A System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
El leaching trenches number,length:
® leaching fields number, dimensions: 1 -(48'W x 141 x0.5'D )
❑ 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.):
Condition of soil and stone inside of the leaching area was dry(an.observation hole was dug through
to the 3/4"-1-1/2"stone and piezometer set). Stome noted as clean with no signs of pastor present
hydraulic failure present, no ponding present in leaching field area.A piezometer was installed at the
end of the leaching field down to 8.5' and did not encounter any water and found to be dry at time of
inspection. Vegetation surrounding the leaching field was normal.
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
A System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
tins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for every page. Barnstable MA 02530 11-18-11
City/Town State Zip Code Date of Inspection
A 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
A
610'
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4352 Route 6A-Acworth Inn [Map 351, Parcel 039]
Property Address
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
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: 41+
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: Plan Date 3-21-92 ; Revised 4-21-92
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:
Established estimated depth to high groundwater by referencing site and sewage plan for system
upgrade by Down Cape Engineering, Inc.of Yarmouthport, MA.Test hole logs from plan indicate that
groundwater was encountered at elevation 27.8, Down Cape Engineering; Inc. also calculated for an
adjusted high water level which was set at a 1.5' difference placing high water at elevation 29.0.The
bottom of the leaching field is at elevation 33.0 and the adjusted high water level is at elevation 29.0
which provide a 4.0 foot seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form -Not for Voluntary Assessments
M 4352 Route 6A-Acworth Inn[Map 351, Parcel 039]
Property Address-
Lisa Callahan
Owner information Owner's Name
is required for
every page. Barnstable MA 02530 11-18-11
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF 139RNSTABLE
k0CATION°�j 5,� /� 1,!5?
SEWAGE # `;�z- .
VILLAGE L .r�� /y) I
---�- ! - ASSESSOR'S !AP Sr LOT • /-
INSTALLER'S NA14E & PHONE NO,
SEPTIC TANK CAPACITYLZAC
I UNG FACILITY:(type) �r�?� , r ..
' (size)/
7 NO. OF BEDROOMS:1`PRIVATE WE L OR PUBC`IC 'WATER
/,
BUILDER OR OWNER �'i?.s-• ,c !�
CJ G i O .✓ �
DATE PERMIT ISSUED:..-.-//
DATE COMPLIANCE ISSUED; _
VARIANCE C RANTgp, yes
. Y7 AY.
I
t� _
No._.1 ,-. (II2 *., F�$ .��.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH APPROVED
TOWN OF B A R N STA B L EBarnstable Conservationawrtraonty.
Appliration for D "pw3al Wurlai Togs „
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at:
L c:-[lion-Address or Lot No.
Owner Address
aCam' ../..r.-•............................... -----•----.............................----
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms..-...- Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Pa Other fixtures --------------------------------- ---- --- ---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Gd Septic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter.-- ............ Depth................
Disposal Trench—No. .................... Width.................... Total Length-----............... Total leaching area....................sq. ft.
Seepage Pit No................. _ Diameter.............--.---. Depth below inlet..--................ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY------- ----------•---•••----•---•-------------------------•-------------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......---..............
(Z Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' ............................•----•--•••••--•--.........----•----....------------•--•--------•-------.........................................................
0 Description of Soil........................................................................................................................................................................
w
x ---••-•-•---------------- -------•-•--...... •------•------.....•-----.............-----•-------------------------•----------------------.•--•--------•-•---•-•••-••-••••............---------........
U Nature of Repairs or Alteratio s—Ans-vyer Lvhgn p ble-7 -��.--.v f J-o y�
...............�f... .- ---•--•---...------•----------..................................-----.............._
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been/is ued b e aar f health.
G�
Signe
i!�'' ................................. .................................................... .... ........................
IYace
Application Approved BY C .. ..�.e,�s.�vu-�°-� ` .-..��.�..�. -.......
Date
Application Disapproved for the following reasons: ................................... ;-......------------.....-----------------------------------------....-------.---------........
......... .............. .......... .. ... ................ ... ................ ....... .................................................... .. ..............................
q. Date
PermitNo. ....../. ........ ............ ;Issued ...............:........... ..................................
Dare
„,,..,ti,,,.r�.-.:�;ti.,.v-.�.,�✓.:,_�.r--� ;>,..-�..:,,y-�`�-'�..a•ti."r-�=-�'t✓:`'”"ti,;.r"uv--�'�s-+`.�...�'.""`.;..:�...-_�^,,.� r•w ..� :;�r.,yi,.�,�� ,�-� �tv.
No.. 3.��.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Dig weal Workw Toii�r<niO erm t -
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual-Sewage Disposal
System at:
/1
................... ••----•-••--•-••----•-•-----••-•----...._�......-•--••••-----------•-•-•-•.................
. 3.s ..................................................... o
LSA,ation-Address or Lot No.
Owner Address
a1. -----------------•-••-------------- ......................................- •••••--••--•.•-••-••........-•-•--••...--•-
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms________________•__________________.__-_._.-Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ......................................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length________________ Width................ Diameter_------------- Depth................
W Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------._--_---. Diameter-_._-._--- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -•--•--•---•--------•--•--•-•----•••••-•--••••--•---•----•-•--•-••••••••......•-•-•.............•--•.......................................................
ODescription of Soil............................................................................... ------------------------........-------------------------••••-•-•------•-••....-•--••...
x
W
------------------------------------------•----._...------------------......----------------------------------•-. ........-•------••••-•-•••--•---•-•-----•-•-••••-•-•••••••••--......._._.._.........
M. Nature of Repairs or Alterations—Answer when a P able--_ _.! �� U / .. ao S
US X yS-X 6....
............................. � .....ic.... .....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—Theundersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board.of health.
Sign Al��- G�--Z i
... _i ...... r Dale
Application Approved By ..........Q. ...... ..�<_ ,..�........................ 1.-.I�. ��.a-.......
- ------
Application Disapproved for the following reasons: ........................... ... ....... ............................................................... .........................
................................................................................................................................................................................................................ ........................................
Date
Permit No. ....../... - t�/� ............................ s �' Issued ..........................
" •. � Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BAR(�NSTABLE
(fErtifirate of C�nmpliartrP
THIS IS TO CERTIFY, That the Individual SewageP Disposal System constructed or Repaired
......------............ .................._(----..._.) ( ---
/ In r Ilcr
at ...... 7/�)... .-�5.._.,,-)........... ........... .... 'a...... ........... ........................... .................. _... ..................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ------.�a..-..: G.
dated ... ..............._................_.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE 1..J_.-._..fl:...`*-....r--. .._ ...._... -...- _. Inspector ......... _\._?......... .................- ......
--_--_,--_-.--_ --_.-----/_-__-,__._____�,________,__._ _,�m_,1__.�__.___.--_---__--_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH- >�(^1 . _..,WEER MUST SUPERVISE
TOWN OF BARNSTABUEArION AND CERTIFY I-- ITING.
THE SYSTFM J�IAS 1P.!-'-ALF>� '? .�T-1;4......
Permission is hereby granted-------------- �,2 G /fi
-------•-
to Construct ( ) or Repair (,.--ran Individual Sewage Disposal System
atNo........... �-,'�-3 s -------- ?5::-- �y.................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No./ t.__ Dated...........................................
........................... <- ............................................................
C -- ---•• { � Board of Health
DATE................i......-. . .f-.. - -------------------•-••--
FORM 38808 HOBBS&WARREN.INC..PUBLISHERS
iL
TOWN OF BARNSTABLE
CF TH E Taw
le�Qy �� OFFICE OF
i DA"3TAN i BOARD OF HEALTH
MAt4 0
°o 039• �� 367 MAIN STREET
HYANNIS,MASS.02601
May 1, 1992
Down Cape Engineering
939 Main Street
Yarmouthport, Mass. 02675
RE: Cummaquid Guest House
Dear Mr. Ojala:
You are granted a variance on behalf of your client, Old Cape Cod Realty, to
replace an onsite sewage disposal system located at 4352 Route 6 A,Cummaquid
with the following conditions:
(1) The septic system plan shall be revised to show the septic
tank cover to grade.
(2) Flow restrictors shall be installed onto all plumbing fixtures,
including shower stalls and -sink faucets.
(3) No more than six (6) bedrooms are authorized due to the
fact the septic system is designed to handle only six (6)
bedrooms. Dens, study rooms, TV rooms, sleeping lofts,
similar rooms are considered rooms according to MA DEP.
(4) The Designing Engineer shall supervise the installation of
the system and shall certify in writing to the Board that
the system was installed in strict accordance to the plan.
The variance is granted because the existing septic system is not functioning.
properly. The proposed septic system is well designed to replace the poorly
functioning system; all the clay will be removed from the bottom of the
leaching facility and replaced with clean sandy fill.
Very truly yours,
oseph C. Snow, M. D.
Chairman
No......_ ��..... :�.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
...-....OF...... ............._.-.. .-._...... ............................
Applirtation for Uhipoii al Worki Tonutrurtialn Vamit
Applicatio is hereby made for a Permit to Construct ( ) or Repair 06 an Individual Sewage Disposal
System at•
................ ._ ..... -------...... .............. ....................... ••-•-• - -_._..__.....-----•---._..._......___.••••. .
r
at-ron dress / ��// or t No •p�
ner �• ddress
a .._... ..... .............
� Installer Address
Q Type of Building Size Lot____________________________Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
04'4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
a Other fixtures ----------•---- ---------••--•• -- -- --
Q - --------------------------------- --------------•------
77
W Design Flow.............____ __ _ _ gallons per person'per day. Total daily flow________ __._.__________________.________.,gallons.
WSeptic Tank—Liquid capacity............gallons gth..........._.... Widt ..`....... Diameter---------------- De __ ............
x Disposal Trench—No..................... Width____ ......... Total Length___________ Total leaching area__..........sq. ft.
Seepage Pit No_____________________ Diameter----_--------------- Depth below inlet.................... Total leaching area......._..........
sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-, Percolation Test Results Performed by.......................................................................... Date-----------------•----------------------
a ' Test Pit No. 1................minutes per inch Depth of Test Pit_______.____________ Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
0 0 G
r = ••• .. •-••----
ODescription of Soil.. --- -----------------------•----------- "-....................................................................
x
---------------------------------------------------------------------------------------•------------------___- -----j ff ---
U Naof Repair o-.Alterations Answer when a cable..._,w-_r�._`�`--�-
---_----- ------•-- ---••--••---------------------------------------------•---- •------••-••-•---•-•----.._.._-•----
Agreement:
The undersigned agrees to install the afor scribed Individua .Sewage Dispos System in accordance with
the provisions of 1.TTLE 5 of the State Sanitary ode— The unde Ig d further rees not to place the ystem in
operation until a Certificate of Compliance has een • ued by the ar of health.
S- A -• ` G
Date
Application Approved By-----
..._...... "Date
Application Disapproved for th f ollo ng reasons---------------------------------------------------------------------------------------------------------------
-------------------------------------................. •-•-••..................................-........................................................................................................
Date
Permit No. Issued .''. Q`..`...............•------------
Date
No............`....�......�� FE ::.C°?..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD CIF HEALTH
.............._.._......................OF....: ^.`....................... ....,.'
Allpfira#ion for Eliipoaal Works Tows rurtion Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair (<) an Individual Sewage Disposal
System at•: '
................ �. It.......... h ... .. �.. ..... . O..Loot ..... ._.... ........................
anon /�d�dress , ? 6.4 I 0
. �...!.........;a: .... ................ T � a-¢--�.... ................................
jp � /� /,Owner �t /� a ,s yr /Address / �j e
Installer ,, Adl
dress
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................. .....Expansion Attic ( ) Garbage Grinder ( )
U
'4 Other—T e of Building No. of persons.:.......................... Showers — Cafeteria
PaOther fixtures ..............• -•-•--•----•--- . ---------------------------------------------------------•--------------------------
W Design Flow.................. ------_--_------_-gallons per person per day. Total daily flow-____:.C...�....-_..................._/:gallons.
WSeptic Tank—Liquid capacity............gallons gth________________ titi�id �_......_ Diameter._..___..._..._. ll• _ _.___....._..
x
Disposal Trench—No. .................... Width....A --------- Total Length_ a......... Total leaching area..�._ _..sq. ft.
Seepage Pit No----_-------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
a ' Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-_____-_-_--.-. .
' ... p ri inch Depth of Test Pit.................... Depth to ground water........................
� Test Pit � 2�� ......ni>nutes er In. �"
Description of Soil.. �' .............. �� ---•---- J-- -----`------------------------------------------------------•------------•
x 61)
V •-•-•••••-••-••-•---•-••--••--•••----•------••-----••-•----•-•------•-•--•--•-••-•------------------••---•••-----••-•-----•--•-••-----•------•••••.-•---•------•••••••----•.._...............--•--•-
W -------------------------------------------------------------------------------------- --- --- .... -- -- - "�. ' '----------------
11
U N t�i e of Repair _o, Alterations Answer when applicable.------== =- //
...'�� �_ . ........ ..... ................................................................ .......
Agreement:
The undersigned agrees to install the afor'edescribed Individuayl9 Sewage Dispo al System in accordance with
the provisions of TITTLE 5 of the State Sanitary%/Code—The under�Ig d further rees not to place the --stem in
operation until a Certificate of Compliance haS been issued b the b`od of health.
�-��
r -Ole
••--•.....------•�'-•--........-•---•------- Date
Application Approved By.._..'7....a�,�G�C�& ..:..._(..:_.. � 4
// Date
Application Disapproved for the olio ng reasons:-----•-•--..•-•--•.......-----••-•-•-•--•--------------------•--•-------------•---•••-•••-•-----•--•...----•-...
t 1 Date
PermitNo...............` } Issued.......................................................
Date
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
�' a�
t !�" ...........OF........ .. f>(,�d- - :. ....................................
Tatifiratr of Tontplianre
THISI,f3 TO ERTI That th Individual Sewage Disposal System constructed ( ) or Repaired ( )
=' -------------4 n-----------
j Installer �t
' f
v ��`
at... ----• . C " lf� •---- ------••----•---•----•-•-
PP P P i (�V----r -------------- dated----- 'f `e CJ . the
has been installed in accordance with the provisions of T > o The State Sanitary Code as described i� t
application for Disposal Works Construction Permit �o._ ._...
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT TjIE
SYSTEM WILL FUNCTION SATISFACTORY. '
�� d ..
DATE. ��._....- .....'�................................. Inspector......... 1 .................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL H
......... .................... ..........
' No......_..2/ ......_ FEE.................•.••••.
ioo1 or , otrttr#ton rrntit
Permission is hereby grante _.."...... ;...... !.t .'��................................................................................
to Construes. ( ):or✓ epair and dlv*dual Sewage Dispe al Sy teu
at No.. ---.... ....... . --
Street Sr �_,
as shown on the application for Disposal Yorks Construction Peral? No._ Dated....2__---....+.....................
----- -------
Board of Health i'
-------------------------
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
C
,9
No......V..........
THE COMMONWEALTH OF MASSACHUSETTS
®A R®
.....OF........ . . -- .......-•--
Appliration for Disposal Marks T'onstrurtion •�t �
Application is hereby made for a Permit to Construct ( ) or Repair ( �rn Individual Sewage Disposal
System at: -
�z'_ _ �i------------- .................................................................................................
--------- --- _
Lo ti�/ Ad1l �r y�
p.C.�1...5 ls� "Cd/ e �a�/. �-- ----------- -------- � r! L.............................................. , .
Own Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms......................... .Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
p' Other fixtures -----__--•_--_____-•-__•-•------_.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. `
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_-____-___..._ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of est Pit.................... Depth to ground water........................
Description of So><I_.____._ �__t✓lam _._.
UNature of Repairs or Alterations—Answer when applicable..,'' _ .o__ _ ___ _.1 ..... �>
•-•.......---•...-•--- ......-----•----------•--------------••-..........•-•---•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system iINrl
operation until.a Certificate of Compliance has been issued by the board of health.
Sig 6d. . ------------•------ ---------------------------P
Date
Application Approved By...... . .. --------------------- 7J_
Date
Application Disapproved for the following reasons:..............................
--------------------------•......•...................... --•---•-•-••--
s
Date
fi
Permit No......................................................... Issued.... c'
- ---------•----•----
Date
y._------------- -- ------
�S
No.. .......... Fn;a..¢.{.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H EA1,,THIle
+v✓ ff 1 E
Appfirafion for Disposal Works Tonstrurtion rpfmit
Application is hereby made for a Permit to Construct ( ) or Repair ( 1)an Individual Sewage Disposal
System
r�at:
Locati n-Add r s or Loot No.
Owner Address r
...J.,���........r r!,�%?�,,r'� tom/ ;!•�,�1��,� �r�� +
Installer Address
Type of Building Size Lot..............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ,) Cafeteria ( )
Pa Other fixtures ------------------- --••••-
W Design Flow.............................. gallons per person per day. Total daily flow....... ..._ gallons.
Pa Septic Tank—Liquid capacity ":.gallons Length................ Width.._.....___.___. Diameter...._ Depth:_........__.__.
Disposal Trench—No--__---_----•-----: Width.................... Total Length.................... Total leaching area...;.:..............sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area...................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...........,.___-__-__.
(i Test Pit No. 2................minutes per;inch Depth of Test Pit.................... Depth to ground water...........................
a' ..................
-------------- `::-----------------------......... ..................
------------•------------•------•-••---............- ..........
ODescription of Soil------------------------------------------------••---•----------......_......------------------------------------------------------------------------......••-•-•.--••--
W ---------------------------•-•---------••-•....... -=-•----------------------•-•---••....----••••--•-- --- ---------------- - -
UNature of Repairs or Alterations—Answer when applicable...^�_ be j �_$ _r _..._ ._._ f._..._.=N._.._
= �
-----------------------------•----------------•-------....------------------------•------•--•-....._..--•---------•--- ! ............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sigd•-•-•---...... •••-•-••••--•-•-••••-•..................................••--•••. . ............•-----..............
r; Date
1 f/
Application Approved By.....yl 9 r e� �,,
Application Disapproved for the following reasons:........................ Date.
............................••••.---•---•....•-•.-••--•-•-••-•-•---•--•-••-•••-•••••---•-•-•-•••••••.......••--•-•••--•-•••••.••.••••---•••••••-••---•.•..-•••-•-•.•.•.-••-•---•--••• --•--•-------•
Date
PermitNo......................................................... Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i
....... ...... .. ..L........OF................. ..:...� _.-:................................
� prtifiratr of C"llutpli tna
TH 1ILS IS T�i( CERTIFY, That the Ind>vidktal Sewage Disposal System constructed ( ) or Repaired (4�
�, r 4 == 17
.�; = y taller { ..
-----^
has been installed in accordance with the provisions of Article XI of The State Sanitary Cod/as escrib d in the
a lication for Dis osal Works Construction Permit No..__....._•.._._:_ .. dated......PP P .T IE ISSUANCE OF THIS CERTIFICATE SHALL NOT EE CONSTRUED AS A GUAES THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
7 .... OF....... .�- . :.:.:. .�
Nod, ..... .. af... .. -,•••- � °' ....... FEE.... -��..........
Disposal Works T itstnution% rrmit
Permission is hereby granted.... r -:__..�`-�-_..-,.,. - - i % ! ..... ,......
t1 ---...
to Constr}�cej( ) or R llair (, a `Individual.Sewage D sposal Syst
atNo.. •, 6; 2... .t4 . ,1`' s>,!tl .. ......._...f�_ 5 .. 2�-x. ................................................
as shown on the application for Disposal Works Construction Perm,it�N6�.................... Dg" a.JIZ.0 r1 j.........
-Bo`2rd �fy)TeaIth
DATE---.. -/ .......... j,[�;✓ �'�
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
/ r
0-7
� Q
3
t s3� h
F yW
C T - _
.o ;�
3t/07
)` Q
: o
00
V4Fr=46= 20"`Y /B/.
� e 4g 1_1 X104 y .
to
:::is Plan does not require
/ P the a.':�pr val of the Board Of S u.ve-
xeG -K
—
x _ t
E1�.'�ii1L 0i SURVEY OFEAHiJJ` A?a.
O�-
4L E w- �414'41 S 7-/9!0/
I
RoTA13L - - -
SA
TEST, HOLE,LOGS
ASSESSORS MAP.-
00" ,_ .351
00" 34.1 34.7 ,
TOP,
JOP a
PARCEL: J9
SUB-SOIL SUB-SOIL- CURRENT ZONING. RF-2 12" 12",
BLO :SETBA CKS
OILS INSPECTION REPORT .
24"
0"S., R.
LOWS SARNSTAK 36"
36
CLA Y,
48" ,
,48
REF: D
-335
PAGE
607—
' PREPARED FOR.
OLD 72"
CAPE t0 REAi TY.�,�_ 6A
TEST DATE:, _OBS H 0 IN - WARSTONS
-7
84" 84" 78
MCLnLAN -
Nows j MONITORING PIPE
LOCA TION" MAP
'CLAY
WITNESS: b0NNA
96" 9 6'0
RIAN KISSUNG, 25.7 NO TES
108'� � '108"
'N
Uls.G.s MAP'
TAKEN,f ROM. HYANNIS QUAD,
PERC RA TT �<2 AYN.11 120"
(1) DA TUM MSL/NGVD
20"
IN'CLEAN MEDIUM $AND CLAY
(2) MUNICIPAL— WA,TER-LS— A vAILABLE.
1327 132"
SAND MIX
150" 21.6
PI TCH=114 FT UNLESS OTHER KISE NOTED.
144" PIPE
4f
-10 -44.
BLUE 156", 217 DESIGN LOADING ALL PRECAST,,UNITS AASH---
CLAY
YED.
.0- ry W
Ir
GR (5) PIPE., OINTS SHALL BE MADE A TER7tHT-,," '
SAND
(6) CONSTTUCTFON DETAILS TO 'BE IN ACCORDANCE KI TH
1800,
�'MA SS. EN VIRONMEN TA L CODE,.77 TLE v
WATER ENCOUNTERED
17.6
98"
PIPE, SET
ONITOR
MED nNE PLAN FOR-PROPOSED WORK ONLY AND SHOULD
SAND
lK 0. 04" 171
AT T.H, 2 (7) MIS��
NOT BE USED ,FOR PROPERTYLINE STAKING.
N T
WATER E COUNTERED '
6'
AT ELtV. 27.8 ,�,
CALC, H16H WATER AT 29.0 , (8) 4 ' A-S�TM-, SEWER PIPE TO BE USED.
'777
00
STEM HAS NOT BEEN DESIGNED TO,
�(9) T-1E SEP77C SY
N
)A 7E 'THE -OF:A GARBAGE GRINDER.
SEPTIC- SYSTEIWIPROFILE
ACCOMOL
0
(10) EXISTING �SEPTIC SYSTEM TO BE REMOVED. SOME
NOT TO 'SCALE
RECORDS AVAILABLE S AT B.0.H.
rLOOR, EL�= 38.3
ELEV. 36.0
COVER OVER PRECAST)
(m/N I
CONCRETE '
N
IN
NOTE- ,LUMBI
RAISED TO OUTLET
tK
NG
BASEMENT MUST BE
ELEV. t,34.7
0 U 1) 0 u 33.5
hv r
-% 15001 GAL. 6", 3/4"- 1,1/2
34,15
W T �STONE
INVERT
ELEv= 3 3.6 8 WASHED
EL vw 33.85 33.0
�5&77C T NK
8 PR6CES'S6'
DEM
-SIZES
7FE S TO N F_ BASE
'po
)0*
INLET , '160
(6m, UP, 10" L
OU TLET,
25 (6UP,' 190�,DOWN)
."WATER , TEST
�14kmNrE �REQUESTEO
BARNSTABLE, EL.z 29.0
DISTRIBUTION., BOX
ON
ADJUSTMENT,'
INSTALLATION 1.2
-ALLOWANCE
TITLE,,Y L, 2 7.8
) .,,. 25�- FOOT REMOVAL , OF
'UNSUIT 'BLE SOIL.
DESIGN. 'CAL CULA TIONS
MEASURE
D 4/20/92
9un ET'
",R EG; 5 0 2,(1
=-660
0645 V GRL) - GPD DISTR UtION BO
FACILITY
25: FOOT, VARIANCE Edb S E 'GARBA 1B
GE; GRINDER IS NOTALLOWED: ,:
SEP TIC',..TA NK
-660 dPD�x;- 1.5 9910 ,GAL.,
'USE��501!�,,' ,.,�GALLON,�,.rANK
EMIR
LILLA N
LtA CHING S1 TE , A ND'�:,SE WA GE
DENOTES , EXISTING CONTOUR.
VPGRADE
�T
GI' D
(2. YS
I SIDES:'
" PROPO SED CONTOUR, . ......
' 'DENOTES
52).
BO TTOM: &Lj,F 672 (1-0) -.7 LOT'-lA C UA40A Q
ID
OF ' RIF.�,,`6k BARNSTA E:�, UID)
OADING WASSA CHUSETS
t, ilk
-672 T AL , ,,,,,
�.'�PREPARM
0 t,
REALTY
Inc.own c�,P;e en aln e&in OLD .� APE COD
-------------------------
CL 'Y MA TERIA L IS �TO,BE REM 0 VED
_g L A
AL
DOlW iZ§A)n�L��ER4..Ll-LQLNN '
d. sur�,eyors E
C1Vi1,_'engirie6ri�&l6n'
W TH CLEA N,MED. SA ND.-
9j9"'Y' A'IN' ,S7REET�R 7F. 6A _
REFERENCE.- PLAN,:�BOOK 6L4 6E
YARYOUD�PORT, MASSACHUSETM 026
——— PA
T
E.
A
'(508)' ,36.24541 FA A _92
t5O8) 36.�"9880
&�AL D
—— 4-2/-92
A PPRO:VED DA
DRA WNC,,CODE, OCC92058, ARNE PLS PE : DA7t TE
V06 .92 0,58
r;r7