Loading...
HomeMy WebLinkAbout0038 MARASPIN ROAD - Health . • ' Barnstable ,0 /-A 8 Westcheste Way :a o Barnstlable I i 4 CommoMvealth of Massachusetts Title 5 Official Inspection Form ° r �I Subsurface Sewage Disposal System Form -Not for Voluntary AssessmentsIV t cam / 38 Maraspin Rd. a . Property Address :+ Tim Cannon i Owner Owner's Name / information is required for every Barnstable V Ma. 02630 9-4-20 ; State Zip Code Date of Inspection City/Town/Town p page. Y p _ 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. Inspector Information on the computer, use only the tab Michael Sears key to move your .Name of Inspector cursor-do not Robert B Our Co INC. use the return key. Company Name 363 Whites Path Company Address South Yarmouth Ma: 02664 City/Town State Zip Code 508-477-8877 S114436 Telephone Number License Number B.. Certification I certify that: I am a DEP approved system inspector in full-compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported'below is true, accurate and complete as of the time of my inspection; and the inspection was performed based,on-my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes ���`•��`�H OFo 'MASS;'G,,�, 2. ❑ Conditionally Passes ' _' ' MICK EL SEARS 3. ❑ Needs Further Evaluation by the Local Approving Authority- S o No.SI14430 4. ❑ Fails 9-4-20 Inspector's Si ature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. . Please note: This report only descrlbes 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. e Sewage Disposal System m•Pa Page Inspection Form:Subsurface S t8insp.doc rev.7/28/2018 Title 5 Official9. P Y 9 Commonwealth of Massachusetts �- Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is BarnstableMa. 02630 9-4-20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: - 2) 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 tan_ k 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): h . l5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection form I; Subsurface Sewage Disposal System Form Not for Voluntary Assessments !� 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is..required for every Barnstable Ma. 02630 9-4-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cost.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired: ❑ 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): ❑ brokenpipe(s) are replaced . ❑ Y ❑ N ❑ ND (Explain below): ❑. obstruction is removed ❑ Y ❑ N ❑ ND{Explain below): 3) 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. a. 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: t5insp.doc-rev'7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form., III Subsurface Sewage Disposal System`Form - Not for'Voluntary Assessments u— 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is required for every Barnstable Ma: 02630 9-4-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool orprivy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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. El 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. c. Other: Y . 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the,following for all inspections: Yes No El ® Backup of sewage into facility or system component due.to overloaded or clogged SAS or cesspool ` ❑ z Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is . required for every Barnstable Ma. 02630. 9-4-20. page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static Liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6." below invert or available volume is less than '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or El n obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high.ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tritiuta`ry to a surface water supply. - ❑ ® Any portion of a cesspool or privy is within aZone 1 of a public water supply .well. ❑ Z Any portion of-a cesspool or privy is within 50 feet'of a private Water supply well. ❑ E Any portion of.a cesspool or privy isless 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 5 of 18 y _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is BarnstableMa. 02630 9-4-20 required for every page. Y Cit /Town State Zip Code Date of Inspection C. Inspection Summary (cont.) E' If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the.;system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® O Were as built plans of the system obtained and examined? (if they were not available note as N/A) - k ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 6 of 18 r - Commonwealth of Massachusetts �m Title 5 Official Inspection Form z Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is required for every Barnstable Ma. : 02630 9-4-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow.Conditions: Number of bedrooms (design): 2, Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 220 Description: r Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatmenfunit? ❑ Yes.® No If yes, discharges to: Is laundry on'a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? d = ❑ Yes ® No ' 2018- Water meter readings, if available (last 2 yeIars 24000 galusage (gpd)): 2019-28000 gal Detail: Sump pump? ❑ Yes ® No Last date anc :of occu present p y Date l5insp.doc•rev.7/26/2018- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form +_ Il; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � i 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is required for every Barnstable Ma. 02630 9-4-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title,5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: May 2015 { Was system pumped as part of the inspection? ❑ Yes,® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/205/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f. Subsurface Sewage Disposal System form - Not for Voluntary Assessments 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is required for every Barnstable Ma., 02630 9-4-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑. Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe):. Approximate age of all components, date installed (if known) and source.of information: 5-22-03 #2003-231 Were sewage odors detected%when arriving at the site? ❑ Yes ❑ No 5.- Building Sewer(locate on site plan): 15 Depth below grade: feet Material of construction: ❑ cast iron z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts +v _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Maraspin Rd Property Address Tim Cannon Owner Owner's Name information is required for every Barnstable Ma. 02630 9-4-20 page. City/Town State Zip Code Date of Inspection D. System Information {cont.)_ 6. Septic Tank (locate on site plan): Depth below grade: eet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000 gal Dimensions: Sludge depth: 4 2911 Distance from top of sludge to bottom of outlet tee or baffle 0 y Scum thickness 8„ Distance from top of scum to top of outlet tee or baffle. ` 18" Distance from bottom of scum to bottom'bf outlet tee or baffle. How were dimensions determined? Sludge judge, tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with in and out tees in place both covers at 4" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of18 Commonwealth of Massachusetts �? Title 5 Official Inspection Form Subsurface Sewage Disposal System'Forrh - Not for.Voluntary Assessments u 38 Maraspin Rd Property Address Tim Cannon Owner Owner's Name information is required for every Barnstable Ma. 02630 9-4-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 - Comments (on pumping recommendations„inletand outlet tee or baffle.condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank.(tank must be pumped at time of inspection) (locate on site plan): Depth below grade_ Material of construction: ❑ concrete ❑ metal El fiberglass ❑'polyethylene ❑ other(explain): Dimensions: Capacity: gallons. Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 F15 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , - (, �. 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is required for every Barnstable Ma. . 02630 9-4=20 page. City/Town State' Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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 is 16x16 with 2 outlet pipes at 17" below grade l5ins .doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 P Commonwealth of Massachusetts Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form Not for Voluntary. Assessments ,>e 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name - information is required for every Barnstable Ma. 02630 94-20`. page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ .Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of'pump chamber, condition of pumps and.appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. y 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type; ❑ leaching pits. number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ` ❑ leaching fields number, dimensions: ❑ overflow cesspool j number: " ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 15 Official Inspection Form III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Maraspin Rd u Property Address Tim Cannon Owner Owner's Name information is required for every BarnstableMa. a02630 9-4-20 page. City/Town State Zip Code Date of Inspection D. System Information -(cont.) 11. Soil Absorption.System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2- 500 gal dry we91s-clean and dry with no sign of failure 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.): t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts ru Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 38 Maraspin Rd. u— Property Address Tim Cannon Owner Owner's Name , information is Barnstable Ma. 02630 9-4-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont:) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r - Commonwealth of Massachusetts -_ ,rp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Maraspin Rd. emu„ Property Address Tim Cannon Owner Owner's Name information is Barnstable Ma. 02630 9-4-20 required for every page. City/Town State Zip Code Date of Inspection D. Sysdtem Information (C'Id t.)'- 14. SkeLtch 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 it ) til a t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Maraspin Rd. Property Address Tim Cannon Owner Owner's Name information is required for every Barnstable Ma. 02630 9-4-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >168" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on,record If checked, date of design plan reviewed: 3-29-2003 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 ground water per plan h Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 L� r T , Commonwealth of Massachusetts +v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Maraspin Rd. u� Property Address Tim Cannon Owner Owner's Name information is required for every Barnstable Ma. 02630 9-4-20 page. City/Town State _.Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included Gra i 4A ©C e fy° /V 0 �i1,Gr'KWM^f�- t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 r S ' TOWN OF-BARNSTABLE 6 7::0CATION 30G �1 4IA'(_A Sol�1 SEWAGE# VILLAGE 134W ST Al Ik ASSESSOR'S MAP&LOT019 075- INSTALLER'S NAME&PHONE NO. l 9 SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) 1-7 (size) �X NO.OF BEDROOMS C BUILDER OR OWNER -906 AMC. A&Vt r1 PERM TDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by " r i �Iq 1 F i Al - i3 F31 a Aa - ao Asa - a9 A3 � y � 93 ` ,N 5 3 O .�. . TOWN OF BARNSTABLE _LOCATION MACA SOi6 Rc)- SEWAGE # VILLAGE QAr1►S� ASSESSOR'S MAP &LOT a" 0-7S--' INSTALLER'S NAME&PHONE NO. f''r G 1 J0 r►m SEPTIC TANK CAPACITY , ?j LEACHING FACILITY: (type) �i T 6' 6 (size) /Gt�b NO. OF BEDROOMS 0- // BUILDER OR OWNER aQ7 f kAr'e-, l4O M40� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility)g facili Feet Furnished by itSDct, p., 1 .�O�C. /ilA d, Jra d D p a . i �s as a ao al p 3 r TOWN OF BARNSTABLE LOCATION I ra; a •� SEWAGE,# Q003-23l VILLAGE ASSESSOR'S MAP &LOT ®'IS t ��.�t { INSTALLER'S NAME PHONE'NO. T�Yts� i�c. -_SEPTIC TANK CAPACITY LEACHING FACILITY: (type) _ 6A. (size) a G'k 13 NO. OF BEDROOMS kip BUILDER OR OWNER''' PERMITDATE 22o3 _COMPLIANCE DATE: Separation Distance.-Between the: ° Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Wafer Supply Well and Leaching Facility' (If any wells,exist on site or within 200-feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished`by otis . , w y, No. � + Fee 51( i �..., ' -\',f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprtcation for Zigool 6pgtem Con6truction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) 45 o$9?6 lystem O Individual Components Location Address or of No. 90A0 O ner's Name, dr sand Tel.No. AJJYAr SArj Assessor's Map/Parcel R011_X ,b;.en-SW_(_ Installer's Nam ,Address,and Tel.No. Designer's Name,Address and Tel.No. 90. -160- 1oc-)3 �3 V 10A S+, MA tiY Type of Building: Dwelling No.of Bedrooms Lot Size 4 I i sq.ft. Garbage Grinder( ) Other Type of Building s 'Ff No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1 I1p gallons per day. Calculated daily flow -330 gallons. Plan Date ty �t�3 Number of sheets OYl-f- Revision Date Title Size of Septic Tank 1000 r.Atia✓ (rxtr WCA Type of S.A.S. YSNt 4,0 Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Signed Date Application Approved by Date 2 c93 Application Disapproved for the following reasons Permit No. ZUO 3 2 j Date Issued 15 7— • �� � � tier ,, '. ,k Fee 5C) �" o-"'" Entered in computer: V = THE COMM NWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION, TOWN OF BARNSTABLE, MASSACHUSETTS Yes : rication for M i` C*patent Co"truction Permit Application'for"a Permit to Construct( )Repair.( ).,Upgrade( )Abandon( ) C 6glpeilelystem ❑Individual Components Location Address or of No. j�,,� { `- Owner's Name,Address and Tel.No. � •1J���y tMY YtS TGb�t PhO �' t'FJS`f'1 ✓"/f� Assessor's Map/Parcel�� / '( )C rf�4iy% Ra.CQ Installer's Nam Address,and Tell.No. Designer's Name,Address and Tel.No. c � \.'1�n� �+ 6V�L.i'far.: t,�Q 'JrNt2tJ'� �1�►Y,�'1'� ;;.���-1, tJt��bwr� 1 a Type of Building: Dwelling No.of Bedrooms Lot Size 14 I6 sq.ft. Garbage Grinder( ) Other Type of Building s FfZ No of Peso sa '• Showers( Cafeteria( ) Other Fixtures` { Desig n Flow gallons per day. Calculated daily flow 330 gallons. Plan Date 4 A) /-)3 Number of sheets 7rl­c Revision Date Title Size of Septic Tank 10JQ ate✓ ��xtrr,✓c, Type of S.A.S. `ic�7 r»L 11,N! t s I;k254,1) ' Description of Soil Nature of Repairs or Alterations(Answer when applicable) �ec.C�.�y.c Yt���� Ut"i 1 Date last inspected- Agreement: The undersigned-agrees to ensure the construction and maintenance of the afore described on-sjte sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- { Cate of Compliance has been issued by this Board of Health Signed Date Application Approved by _ Date S 2 2 6 3 Application Disapproved•for the following reasons j f Permit No. ZUb 3 '"Z3 ` Date Issued 3 z zlea THE COMMONWEALTH OF MASSACHUSETTS i BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (`x Upgraded( ) Abandoned( )by 4try2)c► f C�r+S'lAtr\C'fiD.l Ca at t?O:A � 53V�r iK_ P 004 has been construct in a 'ordance v with the provisions of Title 5 and the for Disposal System Construction Permit No. 2X3_2 3 L dated S 2 7- 6-7 Installer t ,s;. L� C9r1S f y�a�x�J , Designer X?3 ',4 N"Ar K."S'_ The issuance of this ermit shall not be construed as a guarantee that the system w'kl' n i,n s si ne j Date U 3 Inspectorir ij • No. Zoo 3-2-3 ,�— Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEj MASSACHUSETTS i . f lwi5po5ar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair(�<)Upgrade( )Abandon( ) System located at 1_5S5 N` AAW,01 n� d"AY1i . 1 r�i ifSLL� v and asrdescribed 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:Constryction rfust be completed within three years of the date of this Date: S 22 G3 Approved by i 4 i tT t o9-1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PIROTECTI'C `'N MAR 1 7 2003 FAILED INSPECTION TOWN OF BARNSTABLE 1� rG\/ HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 38 Maraspin Road Barnstable, MA 02630 Owner's Name: Bob&Karen Hofmann Owner's Address: Date of Inspection: February 28, 2003 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map:299 Osterville,MA 02655-0049 Parcel: 075 Telephone Number: (508)862-9400 ` CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Nee s urther Evaluation by the Local Approving Authority ✓ Fail Inspector's Signature: Date: March 5, 2003 The system inspector shall sub i a copy of this inspection report.to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 f Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 38 Maraspin Road Barnstable, MA Owner: Bob&Karen Hofmann Date of Inspection: February 28, 2003 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4'times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: 38 Maraspin Road Barnstable, kU Owner: Bob&Karen Hofmann Date of Inspection: February 28, 2003 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 j Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of l I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 38 Maraspin Road Barnstable, MA Owner: Bob&Karen Hofmann Date of Inspection: February 28, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no7'to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or . clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(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. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 38 Maraspin Road Barnstable, AM Owner: Bob&Karen Hofmann Date of Inspection: February 28, 2003 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. I 5 f Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 38 Maraspin Road Barnstable, AM Owner: Bob&Karen Hofinann Date of Inspection: February 28, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n1a Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No r Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No . Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): €wd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL.INFORMATION Pumping Records Source of information: Pumped 1 %years ago-per owner_ Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Jul. 17175-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 38 Maraspin Road Barnstable, MA Owner: Bob&Karen Hofmann Date of Inspection: Februan,28, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 3" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: MeasurinAstick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 38 Maraspin Road Barnstable, AM Owner: Bob&Karen Hofmann Date of Inspection: February 28, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): _ Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) i Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 L- Page 9 of l 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 38 Maraspin Road Barnstable, MA Owner: Bob&Karen Hofmann Date of Inspection: February 28, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'-1000 Qal. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): Liquid in the pit was above the inlet pipe and up into the riser. The pit was in hydraulic failure. The cover was approximately 10"below grade. The bottom to Qrade was approximately 96". CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 d OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 38 Marasvin Road Barnstable, MA Owner: Bob&Karen Hofmann Date of Inspection: February 28, 2003 Map:299 Parcel: 075 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Ac Q 1 r p a A 8 i i3 as a ;to al O 3 3 yl ys 10 a Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 38 Maraspin Road Barnstable, AU Owner: Bob&Karen Hofmann Date of Inspection: February 28, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 40' +/: feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map andthe Cape Cod Commission water contours map,the maps were showing approximately 40'+/-to groundwater at this site. - I This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 Commonwealth of Massachusetts Title 5 Official p Ins ection Form . _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L- wM 38 Maraspin Road, Barnstable Property Address Jeffrey Cannon Owner Owner's Name -- --- — information is gams u Barnstable MA 02630 August 13 2009 required for every - , page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information. ' on the computer, M use only the tab 1. Inspector: O key to move your UU cursor-do not Troy Williams use the return Name of Inspector key. Troy Williams Septic Inspections Company Name — -- --- -- . — 19 Hummel Drive Company Address -- - South Dennis _ MA _ 02660 City/Town State Zip Code (508) 385-1300 _.__ S1682 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,6` ntenanc'&-6f on e sewage disposal systems. I am a DEP approved system inspector pursuant;to Section 19.34 Title 5(310 CMR 15.000). The system: c:S ® Passes ❑ Conditionally Passes ❑ Falis. 3 ❑ Needs Further Evaluation by the Local Approving Authority => ::Jt " ,� Au uc, st 13, 2009 V 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. 38 Maraspin Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsu ace Sewage Disposal system Page 1 of 15 Commonwealth of Massachusetts _ Title 5 official Inspect ®n Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments M 38 Maraspin_Road, Barnstable Property Address — -- --- -- --- , Jeffrey Cannon Owner Owner's Name information is required for every Barnstable MA 02630 August 13, 2009 - - - page. City/Town State Zip.Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Mass DEP at the time of inspection only. This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes or components. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or,repair, as approved by the Board of Health, will pass. Answer yes, no or not determine_d (Y, N, ND) in the.,[]for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain.- N/A ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box._System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 38 Maraspin Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System_Form -Not for Voluntary Assessments 38 Maraspin Road, Barnstable Property Address Jeffrey Cannon Owner Owner's Name information is Barnstable MA 02630 . August 13, 2009 required for_every -- --- 9 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): i ❑ distribution box is leveled or replaced ND Explain: N/A The system required pumping more than 4 times a year due to broken or obstructed i e s . The ❑ Y q p p 9 Y . ppO system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines.in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a.manner which will protect_ public health, safety and the environment: ❑ Cesspool°or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated.wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) , determines that the system is functioning in a manner that protects the public health, safety and environment:. El 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: 38 Maraspin Road,Barnstable•03/08- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 i , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M y 38 Maraspin Road, Barnstable Property Address Jeffrey Cannon Owner Owner's Name information is required for every Barnstable MA 02630 August 13, 2009 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.); The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".., r Method used to determine distance: N/A This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other.- N/A D) System Failure Criteria Applicable to All Systems: . You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or El 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. El than %day flow _ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. [A tributary portion of cesspool or privy is within 100 feet of a surface water supply or El tributary to a surface water supply. 38 Maraspin Road;Barnstable'-03108. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Maraspin Road, Barnstable Property Address ; Jeffrey Cannon Owner Owner's Name information is required for every Barnstable MA 02630 August 13, 2009 - page. Cityrrown State Zip Code Date of Inspection B. Ceftification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system.must serve_ a facility with a design flow of.10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the, questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply El ® the system is within 200 feet of a tributary to a surface drinking water supply El ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone Il 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. 38 Maraspin Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 15 t, ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 38 Maraspin Road, Barnstable Property Address Jeffrey Cannon _ Owner Owner's Name information is 9 required for every Barnstable MA 02630 August 13, 2009 page- Citylrown 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: I 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? M 0 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? 0 ❑ 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. o ❑ 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)] 38 Maraspin Road,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 sa Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I - N 38 Maraspin Road, Barnstable Property Address Jeffrey Cannon Owner — ---- Owner's Name information is required for every Barnstable MA 02630 Au gust 13 2009 — —.�— page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3- Number of,bedrooms (actual): .- 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#.of bedrooms): 330 gpd Number of current residents: 2 — Does residence have a garbage grinder? ❑ Yes [A 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 (gpd)),. 08=48,000gals 9 ( Y g 07=50,000gals Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes. ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter,readings, if available: NIA Last date of occupancy/use: N/A Date Other(describe): NIA 38 Maraspin Road,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 7 of 15 f= f Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Maraspin Road, Barnstable Property Address -- Jeffrey Cannon Owner Owner's Name - information is required for every Barnstable MA 02630 Augst 13, 2009 -�_— page. Cityfrown State. Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Last pumped in 2006, 03, 01 per BOH. Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A _ gallons How was quantity pumped determined? N/A Reason for pumping: N/A Type of System: ® Septic tank, distribution box, soil.absorptionsystem ❑ Single cesspool ❑ Overflow cesspool ❑ Privy , ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and.a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Tank is original to home from 7/17/75. D-box& leaching were installed on 7/2/03 per compliance. Were sewage.odors detected when arriving at the site? ❑ Yes ® No 38 Maraspin Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form.. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 0 38 Maras in Road Barnstable Property Address Jeffrey Cannon _ Owner Owner's Name information is Barnstable MA 02630 August 13, 2009 required for every — page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"+ feet Material of construction:' ® cast iron ® 40 PVC orangeburg ® other(explain): , Distance from private water supply well or suction line: NSA feet Comments (on condition of joints, venting, evidence of leakage, etc.): I Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass. ❑ polyethylene ❑ other(explain) If tank is metal, list age; N/A . years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'X 9' X 6' 1000 gallon 411 Sludge depth: 2' 8 Distance from top of sludge to bottom of outlet tee or baffle 3„ Scum thickness 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 11 How were dimensions determined? Probe Measured 38 Maraspn Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 9 of 15 Commonwealth of Massachusetts Title 5 official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments %< 38 Maraspin Road, Barnstable Property Address Jeffrey Cannon Owner Owner's Name information is required for every Barnstable MA 02630 " August 13, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont-) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet and pvc outlet tee's were present. No evidence of leakage or damage was found. Pumping of tank was recomended. Grease Trap (locate on site plan): Depth below grade: N/A P 9 feet- Material of construction: ❑ concrete" ❑ metal, ❑ fiberglass ❑ polyethylene ❑ other'(explain): N/A Dimensions:." N/A _ -- Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle 7N/A N/A Date of last pumping: date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,. liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A__ Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain). N/A 38 Maraspin Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 Maraspin Road, Barnstable _ Property Address Jeffrey Cannon Owner Owners Name information is required for every Barnstable MA 02630 August 13, 2009. — — page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: N/A N/A Capacity: gallons Design Flow: N/A gallons per day Alarm present: ❑` Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A . *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑� No Distribution Box(if present must be opened) (locate on site plan).- Depth of liquid level above outlet invert Level with 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 was found clean, level and in working order with equal distribution to outlet lines through speed levelers. Pump Chamber(locate on site plan).- Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑'Yes ❑ No 38 Maraspin Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposel System•Page 11 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 38 Maraspin Road, Barnstable Property Address Jeffrey Cannon Owner Owner's Name information is required for every Barnstable MA 02630 August 13 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: N/A Type: ❑ leaching pits number: . - 2-500 gal. ® leaching chambers number. chambers w/stone leaching galleries. number: 25'X 13'X 2' ❑ leaching trenches number, length: ❑ leaching fields number, dimensions. . El cesspool number: - El 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.): Soil was sandy. Leaching was found with a low water level present with stone found dry and'clean. No evidence of hydraulic failure or problems in the past was found at the time of inspection. , 38 Maraspin Road,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Maraspin Road, Barnstable Property Address — - Jeffrey Cannon Owner Owner's Name information is Barnstable MA 02630 Au ust 13, 2009 required for every g page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ® No Comments(note condition of soil, signs of,hydraulic failure, level of ponding, condition of vegetation, etc.)-. N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A _ Comments(note condition of soil, signs of hydraulic failure, level.of ponding, condition of vegetation, etc.)- N/A 38 Maraspin Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments` 38 Maraspiin Road, Barnstable Property Address JeffreyC annon Owner Owners Name information is Barnstable - MA. .. 02630 August 13, 2009 . F. required for every — — 9 ' page. City/Town `° State. Zip Code Date of Inspection D. System Information (cont.) :- Sketch Of,Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks: Locate all wells within 100 feet.. Locate where public.water supply enters the building: Y n. CA/- 4 r t 38 mate Roaq,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15, r Commonwealth of Massachusetts Title 5 Official Inspection Form) Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments 38 Maraspin Road, Barnstable_ Property Address Jeffrey Cannon Owner Owner's Name information is required for every Barnstable MA 02630 August 13, 2009 _ 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: 14+ feet Please indicate all methods used to determine the high ground water elevation.- Obtained from system design plans on record If checked, date of design plan reviewed: 3/29/03 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: AIW.247 Zone B 23.1' _2.4' adjustment You must describe how you established the high ground water elevation: Soil was sandy. Test hole 9.4' below bottom of leaching showed no water found at 14.0'. Groundwater adjustment in area at the time of inspection was 24: Bottom of leaching at 4.6 was found not to be located in the high groundwater elevation at the time of inspection. 38 Maraspin Road,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 • ' TOWN OF BARNSTABLE i �n LOCATION SEWAGE # . � 9t'96+r�w� ., VILLAGE----- �r ��1�-* ASSESSOR'S MAP &LOT-CN-025 INSTALLER'S NAME&PHONE NO. !�•�h SEPTIC TANK CAPACITY MID LEACHING FACILITY: (type. �5u.1�. +�„r�.•,(size) S,-X NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: Z ` COMPLIANCE DATE: Separation Distance.Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by '�� k otis A•Sa O 9 -Box JD I Q SEW�►C;E PERMIT QO. VILLAGE 1_hl.S_ _ALL E.R-.5_ .&M E.-6_A.D D R E_5 S 1 �ULLDER-S_lJ.�1./.l.E_�_Af�_DRE SS j ��V ✓0 - No.----......2..........9- ... FE ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 HEA T "t 100011 OF Aplifirativit for Ui-qposal lVarkii Tomitrurtion Pumit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 4— .7 .I...........0-T-A;k-0.. ...0........ ................................................................................................ Location-Address, or Lot No. PI.-PLI...................................X .................................................................................................. Owne Address .....J& Installer Addres s Type of Building/- Size Lot_-_ ...S, _Csq. feet U DWI.—, No. of Bedrooms__________ _________________________________ Expansion Attic Garbage Grinder ( ) a, Other ' Type of Building ---------------------------- No. of persons.___________________________ Showers ( ) — Cafeteria ( ) P-4 Other fixtures ----------------------------------------------- ------------------------------------------------------------------------ ----------------------------- Design Flow----5--0--------------------------------gallons per person per day. Total daily flow__._.IX-q-Q!........................gallons. P4 Septic Tank—Liquid capacity/9 gallons Length________________ Width--____.--...._._ Diameter__-___..__.._.._ Depth-_______..---. Disposal Trench—No. 1A.CD....... Width____________________ Total Length__________________-- Total leaching area-------------- -----sq. f t. Seepage Pit No____________________ Diameter-------------------- Depth below inle ....... Total leaching area --- ----------sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by----------------------- .................................................. Date--------------_-----_-----------------.. a ,� Test Pit No. I----------------minutesperinch Depth of Test Pit....._.__--___.____. Depth to ground water------------------------ (Xq Test Pit No. 2................minutes per inch Depth of Test Pit-._._..___.___.._... Depth to ground water------------------------ --------------- 7 -P- -------- ........ ...... 0 0 - ...........:.. ....... ....... .... ........... Description of Soil------ Y- Q, ------------------- -------------- ---------------------------------------------- F.-S................... --- r------ U -------------------------------------------------�-'- 'u, ----------- ..........---------------------------------- ---------- --------------------------------- ij U Nature of Repairs or Alterations/------Answer when applicable------------------- -------------- ------------------------------------------------------------- .................................................................................................... --------------------------------------------------------------------------------------------------- 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 bee, issued by t r of health. -4- 9 .... .. .. .. .............. ...................................... ---71- -F1-21- Date Application Approved By...... r--------------------- ........... ... ........... .......7 j --- -- --- ----------- Date Application Disapproved for the following reasons:................................................................................:............................... ......................................................................................................................................................... -------------------------..................... Date Permit No........................................................ Issued..... _V27 ...F............... Date ——--——---------------------------------- No.... ..... d Fl� l1.. ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD O H EA T -.. .... 7.......... OF....... .......................... ...... ..... .. ............. Appliratinu -fur Biapuiiu1 Workii Tuuulrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: nn /� / 14 ri AM �✓ Location-Address or Lot No. =••�I=1 �= �...�_..✓ . :� . 1.... ... -••----------------•-----.-..._........ _ r Owner Address ..- .......................... ..................•--7--- e.r•- ' -�-`•................................ .........................---•--......•-•-----•--•--•••-•. -•-••...•••.............. Installer Address Type of Buildin Size Lot_--_�_.. ---------Sq. feet Dwelling ""—' No. of Bedrooms.._....`..................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons_--.._---_-_-______--_-_._- Showers ( ) — Cafeteria ( ) dOther fixtures --------------- -----------------------------------------------------------------------------------------.......................................... Design Flow..`--___f.--________________________________gallons per person per day. Total daily flow_____------�•!�-___-____.______.....-_._gallons. P4 Septic Tank—Liquid capacity/_q_�=?gallons Length________________ Width.____......._.. Diameter_---__.-..-____ Depth--__.-_------- xDisposal Trench—No. ........ Width.................... Total Length-------------------- Total leaching area----------.---------sq. ft. Seepage Pit No.•___________________ Diameter.................... Depth below inl _____ ____.__.____. Total leaching area-___--.-_-.--__-__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) O7, - 11C;�. 7"16 _ 's aPercolation Test Results Performed bY.......................................................................... Date--------------------------------------- ,� Test Pit No. L...............minutes per inch Depth of Test Pit.................... Depth to ground water-.--------_--__--_---- �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Description of Soil----------- -- ---�---- �� z' -----�------- --�-------- -- vtc�/ U --------------------------------- ..-• - ------------------------- -------------------------------------------------- U Nature of Repairs or Alteration Answer when applicable-------------------------------------------------------------------....----.-..-__---_-_-_---... ------------------------------------------------------------------------------------•-----•------------------------------------------------------------------------- --------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the .State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beef issued by bpoaarrdof health. lg . ..Pie'`...... --------------------------------------- Date•� / ._ - - Application Approved BY ..f_--_ 1__�____.... = ------7 1 �J. Date Application Disapproved for the f 0owing reasons:---•--....-•-------•---•------•------•--•--•----•-•-•-•--•-•---------------------------•-•--••••-------••••-•••- ................•-------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date _ 6 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -✓' .............OF........ ... i!. 1.�f'. ................ 01rrtifiratr of Toutphatta v TH,IIS IS�TOkqE�TIF That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by...rti _..._.. ------- - ----= .J✓ Installat....../X_/­`­`:..'��...... ..... ................ ............................. er ��' has been installed in accordance with the provisions of Ar '' I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.: :_?_�........ .2..%Z___•___--__- dated _______•.__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............................................-.................--••-•-•••----• Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS OS— BOARD OF HEALT a. � 2 ..... ............OF......... .r � � No.................•-----• FEE D Bi_nVo ial lkvrk, ! #rur#ion Prrutit Permission s hereby granted /� ic = to Co tru t ( or" ' epair ( ) an Individual ?Sewa Di .sal System at No r . . ....--'f. -<'�Il . . t.... - Y' t t as shown on the application for Disposal Works Construction P ANo.__r__ �--_--- -. Dated-_ '-1- - �.�------_--- = �C -C.�P-�` --....._.. DATE__ .7 -_7 J Boar of Health �� •... . ------- ----------- ----------------------------------• v FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ASSESSORS MAP : Z�q' TEST HOLE LOGS NOTES: PARCEL : 07S 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOR : 1 )- M� E- � THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF WITNESS : UL� FLOOD ZONE: X �c4vIo BOARD OF HEALTH REGULATIONS. v REFERENCE: IL 1-603(- DATE L CRLA! 2�, zoo 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, �2.4 PERCOLATION RATE: 4 2miN w i / SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO .1 0,�5 - Its L'(. = O.7 q df y INSTALLATION. fir► TH- I 76,135 TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION <�NT ��aA� (��!'c..��3 $5 DETERMINATION, IOSHALL NOT BE USED FOR PROPERTY LINE AI t 1 B �t�n1p Sl `7S 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS SPECIFIED OTHERWISE) LOCATION MAP 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A G i -Sy GARBAGE DISPOSAL. I Law M (0,t� 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) ED(vM MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON C, SAW.> 2•S � � �� 52, ABASE OF 6"OF CRUSHED STONE. ?, EX►Sr1 LEACH F't"r 7-- B6 PUMPED C46!t t .F-la- &8___ (�S• ' �2 $'` ReF- T17z..E.V 6L 0, lz To F, SEPTIC SYSTEM DESIGN rt� Et- 67, 9'-0P2 TOT' -Or- 2,. L�Y�►2 ANI� �P� A� 7� 78 t3ta 3 t ` C. LAye A V0 EA-NJ M gy p,v�v� S►g>ti� , FLOW ESTIMATE 17t / \ 3 BEDROOMS AT GAL/DAY/BEDROOM - 330 GAL/DAY 14IVO 14A10 .-J �pletv477Z _Waj,5_GV//A) ,CIS�'N 2. BP, Aic;rvAZT3 ��- PeSl�nt • '-OF I Q / E `� �� SEPTIC TANK 11�/�a V1E7Z.,#A)05 w/B N /SO �o F Pt'-6Po560 (,E�`iC t?jN�� •11 � EVG ktv �1 GAL/DAY x 2 DAYS GAL �z > G 1 i1/l5_>= U�►!1 TiTc � 2 6 �v a>� P t Soo kc. Sep-tc.. / (iJ USE I�� GALLON SEPTIC TANK��� STl,4�, . REscA� �/ ,5 y t � Ti9��- tF r-k�� a,y-�•I-��� o,�e,.. .�._.�.__._ . _......_-..,.-...N. _.__,._u____..w__�.�._.�..,_�..�..._.�.�.. _..._w...w,. __. ?�..__... t d 3ti SO 1 L ABSORPTION SYSTEM v^'� �"�I=D• r �,`� r ° , ��� �' � •`� ,� ,J � �t t.S7btr� Qt✓ Apt. S r t�GS• �ZS Bt.x 13rwx Z rn� SIDE AREA:�t�2S�Z+ �r3��2.. x :Z x 0.7� = 112.gs G BOTTOM AREA: 25v- 13 x d, 7Y 2q4 . 5d ,� �' � ��15'►'IN� 2.�R. , a 71� .� / ` SEPTIC SYSTEM SECTION 1330 4Pr-> Tar= =ga•45 ��FrM A-OVA4&0 t — t� i _ `To F g0.�s ✓1 6 r5 ` , Bi _.w....____._.__._. e . �.MBHf ..... .............._.._...............-........,__,.o,,..,.., kE-XiSit,v(rA I G'� 710.,7 2"-3 'B Q4vtt S =7 � �I L� ��' /�, sax 7S, 7� «€ . GAL 75.87 �7 �� o � L� L� SEPT 1 C TANK /1 , I,t/ashc� 5 ,f �a o R N SITE AND SEWAGE PLAN • 140, ) vP 0v 4 / 0 1 / LOCATION : ; � a MARA EP14 V' ld SgNf7'AR�PN PREPARED FOR : !?03e!, 7 �-r�,� � � 5.����Y DARREN M. MEYER, R.S. SCALE: 43 VINE STREET DATE: y-I1-d3 DA�'SJ) �Unj� 2-7 l q�Z , t. DUXBURY, MA 02332 DATE HEALTH AGENT (781) 585-0293