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HomeMy WebLinkAbout1308 MARY DUNN ROAD - Health 1308 MARY DUI\N iZOAb --B'a -listable A = 334 - 008 - 001 h Ip I d Town of Barnstable Barnstable Regulatory Services Department Public Health Division D : 63A -200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director, FAX: 508-790-6304 - - Thomas A.McKean,CHO CERTIFIED MAIL.# 7015 1520 0001 2273'3234 March 8, 2016 , Shaw Realty Trust 1308 Mary Dunn Road Cummaquid, MA 02630 , The septic system located at 1308 May Dunn Road, Cummaquid,MA was last inspected on 2/3/2016 by James D. Sears, 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 15.00) due to the following: e The Distribution box is rotted andAhe main line is broken: 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 will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH. Thomas McKean, R.S. CHO Agent of the Board of Health = Q:I\SEPTIC\letters Septic Inspection Failures or Future E01308 MaryDunn Road Mar2016 Parcel Detail Page 1 of 4 --� g41Y� Ij Logged In As Parcel Detail Tuesday,March 8 2016 Parcel Lookup Parcel Info Parcel ID 334-008-001 ) pot er ILOT B Location 1308 MARY DUNN ROAD f Pri Frontage 229m Sec Road DROMOLAND LANE � sec Frontage 293 � � wl Village BARNSTABLE I Fire District BARNSTABLE �. _ I Town sewer exists at this address No Road Index 0993 Asbuilt Septic Scan: ; Interactivey 3340080011 Map �^ 334008001_2 ' �' `� Owner Info ownerTHOMPSON,TERENCE TR w _I Co-owner SHAW REALTY TRUST streetl 18 SCOTT DRIVE f 'Street2 w city NORTH EASTON state�A zip '02356 Country Land Info _ Acres 1.03 use Single Fam MDL-01 zoning 'RF-1 _J Nghbd 01055 Topography-- —� Road f Utilities 3 Location - Construction Info Building 1 of 1 Year Roof G Exi YearBuilt 11964 struct able/Hip ) Wall Wood Shingle Living i�176 Roof p pt AC AS WFGIs/Cm None t 24t—,4; Area Cover Type � i w.... �. .. „ Int, Bed Style,Ranch Wall-iDryWall ) Roomsl` Bedr00mS 1 � fit: 2 __ 42 �"'' Int - Bath�; � 1J7 ;' ,.: m Modell Residential I Floor,:Carpet I Rooms 1 Full-OmHalf .I - Heat Total 4 �' BMT 24 Grade FVerage I Type;-Hot Water f Rooms 5 Rooms Stories 1 Story Hear �il '��Found Poured ConcI 0 °� Fuel. ation Gross 12797 Area i Permit History Issue Date Purpose Permit# Amount Insp Date_ Comments 11/5/2009 New Roof 200905420 $2,500 6/30/2010)2:00:00 AM REROOF-STRP OLD SHINGLES http;Uissgl2/intranet/propdata/ParceiDetail.aspx?ID=28071 3/8/2016 • ��tom, - . ` Town of Barnstable + �uvsr�scE, MASS Regulatory Services,D.epartment Area r,+a'I" Public.Health Division ' 200 Main Street;Hyannis MA 02601 Office: 508-862-4644 F Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6,'2007 ' Rev. 7/6/1.5 DEADLWES TO REPAM-FAMED SYSTEMS (Town Code §360-44 and Title V: 310 CNM 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last yea-r not due to clogged or obstructed pipe ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA. ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or.cesspool ❑Any portion of the SAS, cesspool, or privy'below high groundwater elevation ❑Any portion of-the cesspool within'a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water.quality analysis. (This.system.passes if the Water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components; etc) ❑.Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) OTHER r n� J ICE P� p� ba x Y A1 .1 Ii V)e Repair deadline: 6�_. Q:ISEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc r b• 23 2016 15:34 Jim The Inspector Man 5085349919 page 1 'W:7 D0f CO/ Commonwealth of Massachusetts Title 5 Official Inspection Form A - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7Q 1308 Mary Dunn Road Property Address n+ Shaw Realty Trust Owner Owner's Name / s information is Cummaguid ✓ MA 02630 2-3-16 co 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. Please see completeness checklist at the end of the form. Important:When A. General Information ,►►lit►tur, fillingng out out forms A. 11,44 `1U U�i4 on the computer, \`��`�`�(N Iy�F gS use only the tab 1. Inspector: ;�.' • y key to move your cursor-do not = JWES :R,= use the return James.D.Sears = i key. Name of Inspector Capewide Enterprises, LLC ��•.c'F ��a,'� —It11 Company Name 5 I N SPE �```�� 153 Commercial Street Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S 1623 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 r Title 5(310 CMR 16.000).The system: " t` t ❑ Passes . ® Conditionally Passes ❑ Fails t ❑ Needs Further Evaluation by the Local Approving Authority tT' 2-23-16 C-fnspectors Signature Date it 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. i t5ins•3113 Title 5 Official Ins?ection Form:Subsurface Sewage Disposal System•Page 1 of 17 s 37 3r ('w Feb 23 2016 15:34 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaguid MA 02630 2-3-16 page: Citylrown 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. An failure criteria not evaluated are Y ,. indicated below. Comments: Conn Pass. D Box-main line. The system is a 1000 Gal.Tank D Box and pit 1 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. t: 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 exfiltratlon 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. x A metal septic tank will---'ass 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): is a )r t5ins•3/':3 Ti%5 Official Inspeclon Form Subsurface Sewage Disposal System•Page 2 of 17 i i Feb 23 2016 15:34 Jim The Inspector Man 5085349919 page 3 r Commonwealth of Massachusetts Title. 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 Mary Dunn Road Properly Address Shaw Realty Trust Owner Owner's Name information is ummaquid MA 02630 2-3-16. . required for every C r page. Cityrrown Stale Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes(cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ® broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): Need to replace D Box. Need to repair main line, ❑ 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 ❑ NO(Explain below): C) Further Evaluation is Required by the Board of Health: r ❑ 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: t ❑ 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 (Sins•3/73 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ir'. Feb 23 2016 15:34 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owners Name information is required for every Cummaguld MA 02630 2-3-16 f page. cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 pprn, provided that no other failure criteria are triggered. A copy of the analysis must } be attached to this form. 3. Other: j 4 ti • a �4 D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 3 ❑ ® Backup of sewage into facility or system component due,to overloaded or clogged SAS or cesspools ❑ 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 aIp■ol is less than 6" below invert or available volume is less ? ❑ ® than day flow 17-- i' t5ins•3113 Title 5 OfFGeI Irapadion Form:Subsurface Sewage Disposal System•Page 4 al 17 f i?'i IA Feb 23 2016 15:34 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaquid MA 02630 2-3-16 . pose. 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.) El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system falls. 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 t system owner should contact the Board of Health to determine what will be necessary to correct the failure. C 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 r ❑ ❑ 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, is 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 I' system in accordance with 310 CMR 15.304. The system owner should contact the appropriate is regional office of the Department. a 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System A Page 5 of 17 G i� { Feb 23 2016 15:34 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaquid MA 02630 2-3-16 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 WA) ® ❑ 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): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 r t5ins•31'3 Tide 5 Official Inspection Form:Subsurface,Sewage Disposal System•Page 6 of 17 Feb 23 2016 15:3.5 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630 2-3-16 required for every q page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. { a Number of current residents: 4 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection- ❑ Yes ® No information in this report.) Laundry system inspected? El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2014-23,000Gals 2015-65,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/industrial Flow Conditions: ` Type of Establishment: E Design flow(based on 310 CMR 15.203): canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease.trap present? ❑ Yes ❑ No F Industrial waste holding tank present? ElYes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes El No Water meter readings, if available: A: Wins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 ;3 Feb 25 2016 16:49 Jim The Inspector Man.. 5085349919 page 2 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Curnmaquld MA 02630 2-3-16 required for every i page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Feb 25 2016 16:49 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner owner's Name information is required for every Cummaguid MA 02630 2-3-16 page. Cityrrown State Zip Code Dale of Inspection D. System Information (cont_) Approximate age of all components, date installed (if known) and source of information: 1994 Permit 94-442 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 38'r Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4"PVC SCH 40 Main line broken -need to repair. Septic Tank(locate on site plan): Depth below grade: t 331, 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: 1000 Gal Precast H-10 4" Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Feb 23 2016 15:36 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts m Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owners Name information is required for eve. ry Cummaguid MA 02630 2-3-16 i page. Cltylrown 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 26 2, Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 16 1 How were dimensions determined? Asbuilt-Tape 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.): ' Tank at working level. Tank and outlet cover at 33" below grade w/inlet cover at 9". In and outlet baffle's. No sign of leakage or over loading. i; t Grease Trap(locate on site plan): ; t' Depth below grade: l feet Material of construction: t; ❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain): r,•: Dimensions: • Scum thickness Distance from top scum of to to of outlet tee or baffle P Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3r13 Tim 5 Official Inspection Form:Subsurface Sewage Disposal.System-Page 10 of 17 'i r: �y ' Feb 23 2016 15:36 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaguid MA 02630 2-3-16 page. Cityrrown State Zip Code Date of"lnspection D. System Information (cost.) 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 } Tight or Holding Tank(tank mu st be pumped at time of inspection)(locate on site plan): Depth below grade: i Material of construction: ❑ concrete ❑ metal ❑ fiberglass g El polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date {' Comments(condition of alarm and float switches, etc.): �1 a Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No ry 151na•3/13 Title 5 Official lispeclion Form:Suosurraoe Sewage Disposal System•Page 11 of 17 ri ji id Feb 23 2016 15:36 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaquid MA 02630 2-3-16 page. Cityrrown State Zip Code Dale 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 'rf 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 16"x 16"-39" below grade w/cover at 8". One line out. Wall is broken. Need to replace D Box. 4. 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.): i Yi J 7 )5! Feb 25 2016 16:49 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts _ t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 1308 Mary Dunn Road Property Address Shaw Realty Trust owner Owner's Name information is required for every Cummaguid MA 02630 2-3-16. page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leaching is a 1000 Gal. Precast Pit w/2' stone. Pit at 5' below grade w/cover at 6". Level in pit is 20" below inlet leaching is 20+years. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13*117 Feb 23 2016 15:36 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 .official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1308 Mary Dunn.Road Property Address Shaw Realty Trust , Owner Owner's Name information is required for every. Cummaguld MA 02630 2-3-16 page. CitylTown 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.): f t 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.): a t 'i i' ►�_ l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 tl ri E {�a i, Feb 23 2016 15:36 Jim The Inspector Man 5085349919 page 15 s Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required For every Cummaquid MA 02630 2-3-16' page. Cityrrown_ State Zip Code Dated Inspection D. Syttem Information (cont.) j 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 ;t r= f t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Pape 15 of 17. Feb 23 2016 15:36 Jim The Inspector Man 5085349919 page 16 to { A REA1? _ j � s AYE S/ONE � tiC 13 . sot a . 3 j t. 9 k Sy #w 13 Feb 23 2016 15:36 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Reaky Trust Owner Owner's Name information is required for every Cummaguid MA 02630 2-3-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope - ❑ Surface water ❑ Check cellar ❑, Shallow wells tiD Estimated depth to high ground water 3 + 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: pate ® Observed site(abutting property/observation hole within 160 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: Lot and abutting area high. e� Vi t, Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 16 of 17 Feb 23 2016 15:37 Jim The Inspector Man 5085349919 page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cummaquid MA 02630 2-3-16 required for every page. Citylrown 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` t t� s ru t51ns•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 r: Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1308 Mary Dunn Road 7D Property Address Shaw Realty Trust Owner Owner's Name information is Cummaguid ���N. required for every MA 02630 3-8-16 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 A. General Information filling out forms ``0�g1�r��rrf4U,z on the computer, ` \A OFM,9SS�'''iV'' use only the tab 9 1. Inspector; .`�_�•' key to move your cursor-do not James D.Sears =g," JAMES .m use the return Name of Inspector = y a key i Capewide Enterprises, LLC �'•.o Company Name �''i��•' •. C• 153 Commercial Street °''��F,stri�Nsp�����````�� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-8-16 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaguid MA 02630 3-8-16 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: Up Dated Report. The system is a 1000 Gal. Tank D Box and pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630 3-8-16 requiredd for every q page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to.determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines iin accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and.the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630 3-8-16 required for every q page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 I is less than 6" below invert or available volume is less than 1/day flow Ail- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630 3-8-16 required for every q 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•3/13 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 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630 3-8-16 required for every q 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 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 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaquid MA 02630 3-8-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 2014-23,000Gals Water meter readings, if available (last 2 years usage (gpd)): 2015-65,000Gal's Detail Sump pump? ❑ Yes ® No Last date of occupancy: Present 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•3/13 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 ,M 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaquid MA 02630 3-8-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy,fuse: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 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 GSM , 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name - information is required for every Cummaguid MA 02630 3-8-16 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: 1994 Permit 94-442 2013 Line change & D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 38„ feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 33" 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: 1000 Gal Precast H-10 Sludge depth: 4„ t5ins•3113 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 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaquid MA 02630 3-8-16 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 26 Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scuim to bottom of outlet tee or baffle 16' How were dimensions determined? Asbuilt-Tape 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.): Tank at working level. Tank and outlet cover at 33" below grade w/inlet cover at 9". In and outlet baffle's. No sign of leakage or over loading. 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•3113 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 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630 3-8-16 required for every q 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.): 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•3/13 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 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630 3-8-16 required for every q 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 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.): D Box is 16"x 1T-39" below grade w/cover at 8". One line out. Plump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaquid MA 02630 3-8-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leaching is a 1000 Gal. Precast Pit w/2' stone. Pit at 5' below grade w/cover at 6". Level in pit is 20" below inlet leaching is 20+ years. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �1M 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is required for every Cummaguid MA 02630 3-8-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of pond ing, 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•3/13 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 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630 3-8-16 required for every q page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 A PAR AvF I i 5raNE c / a 3 • f2- i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630. 3-8-16 required for every a page. City/Town State Zip Code Date of Inspection D. System Information (cont) Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells 6. Estimated depth tofhigh ground water: 3 feett Please indicate all Methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators; installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Lot and abutting area high. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1308 Mary Dunn Road Property Address Shaw Realty Trust Owner Owner's Name information is Cumma uid MA 02630 3-8-16 required for every G 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 , ` 6S3 75 No. '" � � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS applitatlon for Misposai *pstem Construction Permit Application for a Permit to Construct( ) Repair(✓S Upgrade( ) Abandon( ) ❑Complete System E Individual Components Location Address or Lot No. 3(�� 4'"`f Q�;n^ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Q�f S�w�vZ " 'moo �C)n Installer's Name Address,and Tel.No. SR �j Designer's Name,Address,and Tel.No. �c�� Type o 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 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 Certificate of Compliance has been issued by this Board of Health. t r- Signed no Date / lD Application Approved by c ` Date ?-- 3 z Application Disapproved by Date for the following reasons Permit No. ; VL 6 Date Issued 4.1 ...,.. r...s.yr'.........�......s...y• nw/Y.A. ,...ry ,t.l ..,,.n � .�yl'.Vf-'4 •�'-•�r.Y"Y r f"....__ .w1 { r'Y� r I 1 � aol65.3 7S i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -- - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0(pplication for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(✓) Upgrade( ) Abandon( ) ❑Complete System /Idividual Components Location Address or Lot No.13(�� (V1�V vnn 2 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Q4f^5}t�� /I� / U A Installer's Name,Address,and Tel.No. SR Rj Designer's Name,Address,and Tel.No. Type of Building: / Dwelling No.of Bedrooms /" Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Othe Fixtures -A Design Flow(min.required) gpd Design flow provided f gpd Plan ' . Date Number of sheets Revision Date 7 '4 Title 1 Size of Septic Tank Type of S.A.S. Description of Soil r y 6 Nature of Repairs or Alteratipns(Answer when applicable) �J�'�z( \J`�(� ,�� �(3 c Date last inspected: Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in 1 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�-reen issued by this Board of Health. Signed gn Date Application Approved by Date e3— Application'Disapproved by Y Date V for the following reasons i /� r' Permit N iJtrr o. , V� �. _ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS ` Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(vill, Upgraded( ) Abandoned( )by ��c n �{ cV� �ri i,/ Lt_ at �[� re f/, )v ne, (Z �`fr%b �ds been constructed in accordance with the provisions of Title 5:£nd the for Disposal System Construction P Od'6 r G T ~p p y o Permit No. dated Installer 'S GCS Designer #bedrooms Approved design flIn. ,�•n� t g] t2 The issuance of this permit shall not be cons�r jd s a%varantee that the system w 1 rim_c A designed.U p Date f l EQ Inspector tom'/ �j ©_f/n"d/�H/�� 1 ---- ------t--`------------------------- ----------- - --- No. ��t b b Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair `Upgrade( ) Abandon( ) System located at ( C-3 t R T n�') i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. ( / Date ` 3 Approved by ; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments M 1308 MARY DUNN RD. { ° / y 9--o o Property Address " ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE MA. 02637 5/25/12 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your MICHAEL O'LOUGHLIN _ cursor-do not use the return Name of Inspector. key. v. Company Name r �, 714 MAIN STREET - Company Address s C YARMOUTH PORT MA 02675,E PI City/Town State Zip Code . 508-362-4942 577 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 Further Evaluation by the Local Approving Authority 5/26/12 - Insp *or'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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 _ h Commonwealth of Massachusetts W Title 5 Official Inspection Form �j Subsurface Sewage Disposal System Form Not for Voluntary Assessments , 1308 MARY DUNN RD. t Property Address ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE MA. 02637 , 5/25/12 every page. City/Town State Zip Code ' Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: 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•11/110 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 1308 MARY DUNN RD. ' Property Address ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE 'MA. 02637 5/25/12 every 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 ore 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'remo'ved ❑`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 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 J Commonwealth of Massachusetts Title 5 Official .'Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 MARY DUNN RD. Property Address A ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE . MA. 02637 5/25/12 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) - 2. System will fail unless the Board of Health (and Public Water Supplier,'if any) determines that the system is functioning in a manner that protects the public health; safety and environment: y ❑ 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 aseptic 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: r **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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool , ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded . or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6"below invert or available volume is less, than Y2 day flow 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 4 M •'' 1308 MARY DUNN RD. Property Address F ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE MA. 02637 5/25/12 every 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. El ® ` 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.] 0 ® 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 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 r Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M ,• 1308 MARY DUNN RD. Property Address ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE MA. ' 02637 5/25/12 _ , every page. City/Town State Zip Code Date of Inspection C. Checklist , Check if the following have been done. You must indicate"yes"or"no"as to each of the following- Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® . Have large volumes of�Nater been introduced to the`system recently or as part of t this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) o S, ❑ Was the facility or dwelling inspected for signs of sewage back up? N. ❑ Was the site inspected for signs of break out? ® ❑, Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility'owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 a 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 - Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Subsurface MARY DUNN RD. . Property Address ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE MA. t 02637. 5/25/12 every page. Cityrrown State . Zip Code Date of Inspection D. System Information Description: Number of current residents 0 Does residence have`a garbage grinder? _ ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes. ❑, No Seasonaluse? ❑ Yes ® No K Water meter readin s, if available last 2 usage 2011/56,000gals. g ( years' g (gl?d))' 2010/46,000gals. Detail f Sump pump? ❑ Yes ® No Last date of occupancy: 4/12+- 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: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17_ r Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 MARY DUNN RD. Property Address ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE f MA. 02637-_ `5/25/12 every 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: TOWN OF BARNSTABLE 7/2/03 SETIC TANK 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 F ❑ . 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 b`e obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract z ❑ Tight tank. Attach a copy of the DEP approval. . ❑ Other(describe): I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I r Commonwealth of Massachusetts � Title 5 Official Inspection For M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 MARY DUNN RD. Property Address ESTATE OF ESTER JiANSSON Owner Owner's Name information is required for BARNSTABLE ' MA. ' 02637 .5/25/12 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont,) Approximate age of all components, date installed (if known)and source of information: TOWN OF BARNSTABLE 8110/93 Were sewage odors detected when arriving at the site? ❑ Yes ® No . 6 . Building Sewer(locate on site plan): •Depth below grade: 3+_ feet Material of construction: ® cast iron ® 40 PVC El 'Other(explain): 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): , Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,;list ace: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,000 GALS. Sludge depth: 12" . t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 MARY DUNN RD. , Property Address ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE ,. MA. `02637 5/25/12 every 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 21" 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 7-1 How were dimensions determined?H TAPE MEASURE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):. APPEARS TO BE IN GOOD WORKING, NEEDS TO BE PUMPED. RISER ON INLET COVER 14" BELOW GRADE. , Y Grease Trap (locate on site plan): a Depth below grade: d _ - feet Material of construction: C ,• 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 l5ins-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 GM ,•`' 1308 MARY DUNN'RD: Property Address ESTATE OF ESTER JANSSON ` Owner Owner's Name information is MA. 02637 5/25/12 required for BARNSTABLE ` every page. City/Town State Zip Code Date of,Inspection . D. System Information (Cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage; etc.): Tight or Holding Tank(tankmust'be pumped at time of inspection) (locate on site plan): Depth below grade: , Material of construction: X . • • ❑ concrete ❑'metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons - F 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.): r ! 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 e Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 1308 MARY DUNN RD. Property Address ESTATE OF ESTER JANSSON' Owner Owner's Name information is required for BARNSTABLE MA. 02637 =. 5/25/12 ` every page. Cityrrown State Zip Code Date of Inspection. D. System Information (con .) 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.): APPEARS TO BE IN GOOD WORKING,RISER 10"BELOW GRADE. Pump Chamber(locate on site plan): + Pumps in working order: j ❑ 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: l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System YPage 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < M 1308 MARY DUNN RD. Property Address ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE MA.r 02637 5/25/12 every page. City/Town r State; Zip Code, Date of Inspection D. System Information.(cont.) Type: A. F ® leaching pits `• number: 1-6'X6' ❑ leaching chambers r x number. ❑ leaching galleries " number: ❑ leaching trenches number, length: ❑ leaching.fields, P number, dimensions: El 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.): APPEARS TO BE IN GOOD WORKING ORDER,60-70% OF LEACHING HAS BEEN USED IN THE PAST, 10"OF EFFUENT IN PIT AND NO SINGS OF HYDRAULIC FAILURE. RISER 4" BELOW GRADE. - k 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 ❑l No t5ins•11/10 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 yr 1308 MARY DUNN RD. Property Address ESTATE OF ESTER JANSSON Owner Owner's Name information is required for BARNSTABLE MA. 02637 5/25/12 . every page. City/Town State` Zip Code Date-of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions , Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ,.gg Commonwealth of Massachusetts a Title 5 Official ln9pecet on Fora Subsurface Sewage Disposal System.Form ; Not for.Voluntary Assessments 1308 MARY DUNN RD. _ Property Address P Y d s re ESTATE OF ESTER JANSSON Owner — -— --- —— -- ---- Owner's Name Information is. required for BARNSTABLE __ MA. ' 02637 5/2_5/12 every page. City(Town State' ZIP.Code Date of.inspeclion .D. System Information cont Sketch Of Sewage Disposal_System: Provide a.view of'tie sewage disposal system`;`mr'luding ties to at least two permanent reference'tandmarks br'tienchrriarks. Locate all wells within_1'0-0 feet..Locate ; where public water supply enters thebtailding: Check one of the boxes below;, ® hand-sketch in the area below ❑' drawing attached separatelIA . r, ! , A ) 3-7 'oe 6` l5ins•11r10 TiUe 5 Official Inspection Form!Subsurface Sewage Disposal Syslem•"Page 15 of 17. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1308 MARY D U N N RD. Property Address ESTATE OF ESTER JANSSON _ r Owner Owner's Name information is required for BARNSTABLE 'MA. 02637 5/25/12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.), Site Exam: ❑ Check Slope i ❑ Surface water Check cellar ❑ Shallow wells ,. 29'+- 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 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: / CAPE COD WATER TABLE CONTOUR MAP. You must describe how you established the high ground water elevation: EXISING ELEVATION IS 80 BOTTOM OF LEACHING IS 11'BELOW GRADE WATER IS AT ELEVATION 40. 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 s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1308 MARY DUNN RD. " Property Address ESTATE OF ESTER JANSSON Owner Owner's Name ; information is gARNSTABLE MA.' 02637 5/25/12 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B; C, D, or E checked ® Inspection Summary D (System Failu"re 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 t l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 • i c� COMMONWEALTH OF M./1SSnCII tJSE'I"I'S = EXECUTIVE 0FFICL OF LENV J ItONMEN'I'AL AYFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION q ) TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �//a/ O Property Address: 30 S Owner's Narne: Owner's Address:P0.1371 � y= Date of Inspection: a 1 Name of Inspector: (please print) M IC k CLt✓l (Jt(,...p(d Q h 11y� Company Name: ' U Mailing Address: a,. Oa 6-15 Telephone Number: O - 6Ci 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 CA1R 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: a I I D r? 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. , Notes and Comments ****This report only describes conditions at the time of inspection and underlie 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 I Page 2 of I sr OFFICIAL INSPECTION FORM — NOT FOIt VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continue(l) Property Address: � p g' /► Il�t/l�h � �� Owner: _ --- Date of Inspection: 1 lnspection Summary.: Check A,B,C,D or El AaMAYS cumlilete all cif Section D A.' SSyystent Passes: V .1 have not found any information which indicates that any of tlrc failure criteria 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated arc indicated belowscribcd in 310 ChIR Cornnrcnts: I3. System Cood ition n tty 11115SCS: One or more system components as described in the "Condit repaired. ional Pass" section need to be replaced or The system, upon completion of the replacement , r repair, as approved by the Board of I-Iealth, 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 Ilcalth. *A metal septic tank will pass inspection if it is structurally sound, not IcAing 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 pipc(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)arc replaced obstruction is removed ND explain: 2 ` Page 3 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .:CERTIFICATION(continued) Property Address: U t�,oyt nn Owner: __ti'QjdkkA�jm�. , _ Date of Inspection: � C. Further Evaluation is Required by the lloard of Flealtlr: Conditions exist which require further evaluation by die Board off Icalth 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 nianner 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 Hcalth (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 snore front a private water supply well**. Method used to detennine 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 . r Page d of I 1 v OFFICIAL INSPECTION DORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: DJVtkP%C Owner: Date of Inspection: 6 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ V 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 _ _V/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool lLiquid depth in cesspool is less than G"be'lo\v invert or available volume is less than ''V,day* low Required pumping more than 4 times in the last carclogged NOT due to Y or obstructed pipe(s).Number / of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. t Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Il N Any portion of a cesspool or privy is within a Zone i of a public well. H tr Any portion of a cesspool or privy is within 50 feet of a private water supply well. ►► a Any portion of a cesspool or privy is less titan 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ('Phis system passe; if the well water- analysis, performed at a DEP certified laboratory, for colifornr 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 ppnr, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma (Yes. 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 I ealth to determine what will be necessary to correct the failure. E. Large Systcrrrs: To be considered a large system the system ["list 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: (Tire following criteria apply to large systems in addition to the criteria above) yes no the systern is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributar t o a surface drinking water X g supply pl Y 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 L 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 systern owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 v OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART I3 CHECKLIST Property Address: aAeA Owner: Date of Inspection: 7,111 p6 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No z ✓ _ 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 ? V 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 oil: 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)[3 TO CMR 15.302(3)(b)] I 5 Page G of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: Qbk t\ Owner: �P Date of Inspection: 01 l=0 RESIDENTIAL FLONV CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x It of bedrooms): Numbcr of current residents: O Does residence have a garbage grinder(yes or n : Is laundry on a separate sewage system (yes or®):_ (if yes separate inspection required) Laundry system inspected (yes or no):— Seasonal use: (yes or ro — Water meter readings, if available (last 2 years usage(gpd)): _ Q� ( 3 pOO Surttp pump(yes or(n ): — 1- Last date of occupancy: IS L a-:�l Doc) t,r COMMERCIAL/INDUSTRIAL 'I"ypc ofestablishrucm: Design flow(based on 310 CMR 15.203): �d Basis of design flow(scats/persons/sgft,ctc.): 6l Grease trap prescnt(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): Pumping Records GENERAL INFORMATION Source of information: Was systcm pumped as part of tltc inspc tion (yes o n V F If yes, volume pumped: gallons -- I low 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 systcm owner) Tight tank —Attach a copy of the DEP approval Other(describe): Approximate age of all cornponcrits, date install d if kn w ( o n)and source of informal'' ron: a y R �q Were sewage odors detected when arriving at the site (yes o n . 6 I'age 7 of I v OFFICIAL INSPECTION FORM - NOT FOIL VOLUNTARY ASSLSSME FS SUBSURFACL SEWAGE DISPOSAL SYSTF,T\7 INSPECTION FORM PART C SYST M INFORMATION (comtinucd) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of constriction: cast iron '10 PVC other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, ctc.) SEPTIC TANK: (locate on site plan) Depth below grade: 30a 'k"Ajr'- ,cOVC.. -%*,w JV-Q t, 114�t k,e�otu� o�o�e Material of construction: V/concretc—metal -_- fiberglass __ polycthvlcnc _other(cxplain) — If tank is rectal list age:_— Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: JOW �Ca Sludge depth: Il Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: a Distance from top of scum to top of outlet tee or baffle: 6 u Distance from bottom of scum to bot�of outlet tee or baffle: 13 How were dimensions determined: �, Comments(on pumping recommendation , inlet and Outlet Ice or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): GREASE TRAP: —(locate on site plan) Dcpdi below grade:— Material of construction:—concrete—metal _fiberglass polyethylene_other (explain): _ — Dimensions: Scum thickness: Distance from top of scum to top of outlet ice or baffle: Distance from bottom of scum to bottorn of outlet ice or baffle: __ Date of last pumping: Comincnts(on pumping recommendations, inlet and outlet (cc or baffle condition, structural intcgrit),, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page R of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUI3SUILi ACE SL«'AGI? DISPOSAL SY,TEI I INSPECTION FORM PART C Si'STEM INFORMATION (continue(l) I'roperty Address: _��` Owner: to Ik - — ------- Ime of Inspccio : a { I'IC11'I'or IIOLUING 7 ANK: (tank nmst be punrpetl at tinge.of inspectiun)(lucate On site plan) Depth below grade: Material ofconstruction: __concrete—_rectal_—filtcrglass _..I't'I)clhvlenc _ other(cxplaill - Capacity: __--gallons Design Flow: — ---_ gallons/day Alarm present (yes or no): Alarm level: _ Alarm in working order(yes or no): Date of last pumping: -- Cto mmotar; (anrntilion of nlnt-m and flont mwilelitia, etc.): DISTRIBUTION BOX: L (if present must be vpcnc(j)(locatc on site plan) Depth of liquid level above Outlet invert: 0 C0111111Ctlt5 (I)otc If box Is level and dlstrlbtlti011 to Outlets C(Itlal, any evidence of'solids carryover, any evidence of leakage into or out of box, etc.): PUNJP CIIAMBEJt: . (locate on site plan) Purnps ill working order(yes or no): Alarms in working order(yes or no): COIIIIIICntS (note condition of purilp chamber, condition of pumps and appurtenances, etc.): Y, Page 9 of I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a6m i MM" C'&, �so Owner: Date of inspection: L 6 / SOIL ABSORPTION SYSTEM (SAS): V (locale on site plan,excavation not required) If SAS not located explain why:. TypS (/ Icaching pits, number: A-- 6 6 leaching chambers, number: leaching galleries,number:. leaching trenches,number, length: leaching fields, number,dimensions: _ overflow cesspool, number: innovative/alternative system Type/nanie of technology: Conunents (note condition.of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, ctc.): 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 or no): 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.): ]'age 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUI3SUIUTACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAIZT C S'"STEM INFORMATION (Continued) Property Address: 13w Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a >sketch of the scwaf e disposal system including tics to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ^^ W t1 10 Pil ge I I of I OFFICIAL INSPECTION DORM — NOT FOR VOLUNTARY ASS liSSN1I..,N'I'S SUBSURFACE SI?WAGIE, I)1S1'OSA1., SYS'I'I;1\1 INSPECTION FORM PART C SYSTEM INFORMATION (continual) Property Address: J QB /11 Owner: Date of Inspection: V SITE- I;XAA1 Slope Surface water Check cellar Shallow wells Estimated depth to ground water 'Act feel 4- Please indicate(check)all methods used to deterinine the Iligi, ground water elevation: Oblained from systcnn, 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 [bard of 1-Iealth-explain: _Checked with local excavators, installers- (attac.,h,� u ocnren n tatio V Accessed USGS database-explain:_ �C� You must describe how you established the high ground water-elevation: I I No....�.�.._�y 2 FEB.....�`....... ............... t THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH TOWN OF BARNSTABLE Apphration for Diripwm! Murlw Towitrnr#ion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( jt�an Individual Sewage Disposal System at: .......9.30 ........... .. -� �•--- --•---........ •--•••......!K�-33 _.... o ..Qom.:_®v._t..... ation--Add ress . or Lot No. ..........��} .... -----•----•............................. •----•------._.-------•-------------.... ----------- -------. ------•---------. SS ........... . ... ..... �- 1 .. .. .... ller .. ...---••- �. Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms----------oZ._-----------------------------Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building _ .___.. No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------------- W Design Flow...............................5_5......gallons per person per day. Total daily flow.....__..__.._.._..•..._.__�.�®.._...gallons. WSeptic Tank—Liquid capacityla ..gallons Length__1_:5--_ Width... Diameter................ Depth..... ........ x Disposal Trench—No. .............. ..... Width.................... Total Length..................... Total leaching area....................sq. ft. 3 Seepage Pit No.._-__--............. Diameter---1�---------- Depth below inlet_......?.......... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) '-, Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •...--•--••--•--•-------•------•-----•--••••--••-•••-•---•-•••---••---•---•-------•................•......................................................... 0 Description of Soil........................................................................................................................................................................ U .......•-•••--••-•••......-----•••-•...................••--••--••---•--••••----••-••-•-.............---••••-•-----•••-•---••------•-•-••-----••--••••-••••-••--•-••-•-•---•-----•-...................--- Wt Nature of Repairs or Alterations—Answer when aplicable._._p ; .. - ..c - ................................... 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 issued by the board of health. Sined -`Y1�..` .............. ............... . ......... I. ..1. .y...:...... . 99�� ........................ F1APPlication Approved By --------�--` ....... -- ..:............... ......�t� Application Disapproved for the following reasons: ............ .................................. .................:................................. ............ ........ .......................................... ................... ..... ............. QDate Permit No. ! �..�... .Y.Z........... ... Issued ........ .... /fF.y....................... Date S + Do No.---.........�-y... ��..Q. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C ✓// ` TOWN OFMARNSTABLSE r } �,���lirtt#iunl�urw �1i��uun� fur-l:,� C�ugtu#rnr#tun rruti# Applicat do is thereby made for a Permit to Construct ( ) or Repair ( dan Individual Sewage Disposal System at - --- cation-Address or Lot No. ..................... ....!�?...,"..C..,_.j...... ;_ a ` x. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms.......... _. _Expansion Attic Garbage Grinder Other—Type of Building aR_,oAA__�. .0_ No. of persons____________________________ Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ _ _ -------------------- --- -----------------------------•-•----------------•------- W Design Flow_______________________________Z5R......gallons per person per day. Total daily flow.........................._.,2 ......gallons. W Septic Tank—Liquid capacity.�G�?._gallons Length__- .:5�. Width__`1�5----- Diameter---------------- Depth__..�L__....... x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter---/-Q-........... 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 ........ ••---------------------------------------------------------•.... ------------------------•-----------••.... _•..... •-------- •..... -----...... •--- •---•- 0 Description of Soil--------------------------------------------------- . ---•-----•-----•---------------------------._._._..__..-------:- -----•---------------------------•--------__----- V _....•--------•••-•••--••••---•--••-•...................•••--•-•-•-•-------•-•-•------........----•--••••--------------•--------•-----------•••--.••-•-..•--._.__...••-•••--•--....•••...-----•-•_-_... Nature of Repairs or Alterations—Answer when applicable... ___ a ..... .. ... ..... x�^ 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 issued by the board of health. Signed .`�y1 ..' C`�cJv ' ...................................... .............. .... .3 '1-y...:--.... gat Application Approved By ....C_ C �. . ................. .....................- � y�9�--y...-.. Application Disapproved for the following rea.fonf: . ............. . ..............................--..........................:.---.................. . .........................:....................... . ................ ......... .................. . ................................................ Date Permit No. �.............................................. Issued .................... Y...�� � -: c Date ------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ate of Tantyliance THIS IS TO CERT FY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ......... ' ......._... M -------------------- ...._-------- ----..... .......-......._......... .. -- .................- h,t:aiet at . ...1.3...0. ...........�a.C.y....�.-lnn---------------1'��.- ----------- --------------...__.._.. .............. . .. ......................... .......... .. 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. .......... dated ..�r.�..�` -- `..`1......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. J O� DATE..._------- _.... ..........._....._--------_. Inspector U - --------------------------------------------------------- ------ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �y ��/y2 TOWN OF BARNSTABLE Sd 41 -- No. .............. FEE........................ Disposal Morkii Tung#rudiun "Vrrmi# Permission is hereby granted �_, : -- ---- ------------l�MRe-------------------------------------------------------------------__-_____________ to Construct ( ) or Repair �) an In "vir ual ewage Disposal System atNo....130-R___ _ ._ M_Jv, ----------------•-•-------------str«r___-..__--------------- ` as shown on the application for Disposal Works Construction Permit No.c�y_- Yy2_ DL1, _____— -- q-- y.................. ......................... ...................... ---- L Board of Health DATE , FORM 36508 HOBBS&WARREN.INC..PUBLISHERS Page G of l 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY•ASSESS Il ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I'AR'I' C SYSTEM INFORMATION Property Address: &LL=Rf`1 Owner: Date of Inspection: _ a 111 O LO.�V CONDITIONS RESIDENTIAL Number of bedroor s (design): 3 umber of bedrooms(actual): a. DESIGN flow bas on 310 CMR . 03 (for example: l 10 gpd x It of bedrooms): Number of current r 'dents' a Does residence have a garbage grinder(yes orn ; Is laundry on a separate sewage system (yes or®):_-[ifycs separate inspection required] Laundry systcm.inspected (yes or no):— Seasonal use: es or 10 Water meter readings. if available(last 2 years usage (gpd)): — Qa _.: 3�oQ0j Sump pump (yes or n ): Last date of occupancy: t COMMERCIAL/INDUSTRIAL 'type of establishtucnt: Design flow(based on 310 CMR 15.203): d Basis of design flow(scats/persons/sgft,ctc" bt Grease trap present(yes or no): 4 Industrial waste holding tank present (yes or no):Non-sanitary waste discharged to the Title 5 syste_ In (yes or no): Water meter readings, if available: -- Last date of occupancy/usc: OTIIER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system um cd as La'��3. Y p p part of the inspc lion (yes or n :, If yes, volume pumped: gallons -- Flow was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _ —_— VSeptic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy .. `Shared systein (yes or no)(if yes, attach previous inspection records, if aiiy) � 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 f Other(describe): Ap�rroximate ase of all components, date install d(if known)and source of information: Were sewage odors detected when arriving at the site(yes o n 6 TOWN OF BARNST(ABLE LOCATION i O ("� (\ V SEWAGE# � "' OS73 VILLAGE ASSESSOR'S MAP&PARCE INSTALLER'S NAME&PHONE NO. � f G/��. ) o�et a 000 SEPTIC TANK CAPACITY LEACHING FACILITY.(typef� '� (size) NO.OF BEDROOI IS OWNEROsh®���1 PERMIT DATE: COMPLIANCE DATE:, ! `L 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) A, Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) - Feet FURNISHED BY ouw A 1= � G'1 A31 � a. 63 � 7 TOWN OF BARNSTABLE G LOCATION 136 S-Not, 4), (1 SEWAGE # Cl y t44 a VILLAGE ASSESSOR'S MAP & LOT .33Y.-doW•dal INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY I On Q Qm LEACHING-FACILITY:(type) size) NO. OF BEDROOMS " _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 'M/��, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �' VARIANCE GRANTED: Yes No 'Y sa s "