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HomeMy WebLinkAbout0064 MAUSHOP AVE - Health 64 Maushop Avenue Barnstable A=218096 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, ,M 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 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. A. General Information I ! � I 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 3-17-15 In rector'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 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existingtank is replaced with a complyingse tic tank as approved b the Board of P p P pp Y Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f S Commonwealth of Massachusetts m W Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 64 Maushop Ave Property Address Nathan & Megan Connelly f Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 page. City/Town State Zip Code - Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): , ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to,a broken, settled'or'uneven distribution box. System will pass inspection if(with'approval of Board of Health): ❑ broken pipe(s) are replaced ❑ •Y ❑ N + ❑ ND (Explain below): ❑ obstructiorris removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ 'N.' ❑ ND (Explain below): 4 „ t ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N' ❑ ND (Explain below): ❑ obstruction is removed ❑ Y. • ❑ N ❑. ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR - 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 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 an Y l pp � Y) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I 4 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 page. CitylTown 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- 1 0,000g pd. ❑ ® 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 ❑� El 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 y Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64 Maushop Ave Property Address P Y Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 page. a City/Town State Zip Code Date of Inspection _ C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? El ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 64 Maushop Ave Property Address r Nathan & Megan Connelly Owner Owner's Name information is Barnstable MA 02630 3-17-15 t required for every _ page. City/Town State Zip Code Date of Inspection D. System Information Description: i 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 Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3-2015 Date Commercial/Industrial Flow Conditions: t Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day d P y�gP ) Basis of,design flow(seats/persons/sq.ft., etc.): Grease trap,prese,nt? El Yes ❑ No Industrial waste holding tank present? ❑ Yes 0 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 a M 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 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: Owner--pumped 2013 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is Barnstable MA 02630 3-17-15 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of.information: 1979 4 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 9011 Depth below grade: feet Material of construction: ® cast iron N 40 PVC ❑ other(explain): Distance from-private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): ' Depth below grade: 84",feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: - years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" t5ins•3/13 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 W Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64 Maushop Ave - Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15_. 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 M 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 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.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cost:) - Type. ® leaching pits number: 2-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: . ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: , ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits in good condition with water level in pit"E" at 12" below inlet invert. Pit"F" had water level and stain lines at 48" below inlet invert. 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 M 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . �M 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 ` page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ; Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately P - - .- 3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ F Title 5 Official Inspection Form Im Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M sv. 64 Maushop Ave Property Address Nathan & Megan Connelly Owner Owner's Name information is required for every Barnstable MA 02630 3-17-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file T { S _ I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts t Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , ,M 64 Maushop Ave. Property Address } Howard & Lillian Richardson Owner Owner's Name information is g required for every Barnstable Village MA 02668 7/11/11' page. Cityrrown State '' Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms " on the computer, use only the tab 1. Inspector: key to move your VVV«< cursor-do not Ricky L. Wright + ' use the return Name of Inspector key. B & B Excavation, Inc. - + Q Company Name _ - 14 Teaberry Lane Company Address Sandwich MA 02563 Cityrrown n State + Zip Code 508-477-0653 S14595 Telephone Number .License Number i B. Certification r 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 - 7/12/11 Inspector's Signature Date " The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within'30 days of completing this inspection: If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner. and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under. the same or different conditions of use. t5ins•09/08' s Title 5 Official Inspection Form:Subsurface Sewa a Disposal System•Page 1 of 17 1 i f s, ` Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments 64 Maushop Ave. Property Address Howard Richardson Owner Owner's Name information is 9 required for every Barnstable Village Ma - 02668. 7/11/11 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: ® 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: r 13) System Conditionally Passes:, r El 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.r If"not a 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): i t t5ins:09/08t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 rm z _ i Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments 64 Maushop Ave. Property Address Howard Richardson Owner ' Owner's Name information is Barnstable Village Ma 02668 7/11/11 required for every g _ - page. Cityrrown State w, 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 iri 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): ' k. ❑ 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): ' r ❑ 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 ordef 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 t5i6s•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 64 Maushop Ave. Property Address Howard Richardson r. Owner Owner's Name information is required for every Barnstable Village Ma 02668 7/11/11: page. Citylrown 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. . G . . El The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or- more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be ' attached to this form. ` 3. Other: ti 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 - 0 ® Discharge or ponding of effluent to the'surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ' ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G7M 64 Maushop Ave. Property Address Howard Richardson r Owner Owner's Name information is g required for every Barnstable Village Ma 02668 7/11/11. -_ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4,times in the last year.NOTdue 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. El ® 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. n , For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ; ❑ ❑ the system is within 400 feet of a surface drinking water supply, ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question'in Section E the system is considered a significant,threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the-Department. t5ins•.09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , G1M 64 Maushop Ave. Property Address Howard Richardson Owner Owner's Name information is g required for every Barnstable Village Ma 02668 7/11/11 page. Cityrrown State Zip Code Date of Inspection , C. Checklist f 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 V available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected forsigns 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? ' ❑ M. 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)] x D. System Information Residential Flow Conditions: Number of bedrooms('design): 4 Number:of.bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example:'110 gpd x#of bedrooms): 440 t5ins•09/06 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. wM 64 Maushop Ave. Property Address Howard Richardson Owner Owner's Name information is Barnstable Village Ma 02668 V11/11 required for every g page. City/Town State Zip Code Date of.lnspection D. System Information Description: + Number of current residents: 2 Does •residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes :® No , s Laundry system inspected? El Yes ® No i Seasonal use?. ❑ Yes ® No^ , Water meter readings, if available(last 2 years usage(gpd)): - n/a Detail: R ` Sump pump? ,,'; ❑ Yes ® No Last date of occupancy: current -, Date - Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑' No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tittle 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 C" 1 ` t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Maushop Ave. s M Property Address Howard Richardson k Owner Owner's Name ' information is required for every Barnstable Village Ma 02668 7/11/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information r Pumping Records: Source of information: a Was system pumped as part of the inspection? m ® 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 p - Shared system (yesror no) (if yes, attach previous inspection records, if any)= El Innovative/Alternative technology. Attach'a copy of the current operation and y. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 64 Maushop Ave. Property Address , `- Howard.Richardson w ' Owner Owner's Name information is Barnstable Village Ma 02668 7111/11 required for every g _ , page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 25 years est. Were sewage odors detected when arriving at the site?' ❑ Yes ® ' No Building Sewer(locate on site plan): Depth below grade: 10 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): . µ' Distance from private water supply well or suction line: >20 r. feet , Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared,to be in good shape no signs of leakage'or blockage. Septic Tank locate on site plan): P ( P ) . Depth below grader F 9 - feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) A. If tank is metal, list age: - yealrs Is age confirmed by a-Certificate of Compliance? (attach a copy of certificate) ❑' 'Yes ❑ `No Dimensions: 5.2x5.2x8.6 y Sludge depth: t5ins•09108 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 64 Maushop Ave. M Property Address Howard Richardson Owner Owner's Name _ information is required for every Barnstable Villa a Ma 02668 7/11/11 9 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.),, Septic Tank(cont:) 24., Distance from top of sludge to bottom of outlet tee-or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle, Distance from bottom of scum to bottom of outlet tee or baffle 6': ~ How were dimensions determined? scour stick Comments(on pumping recommehdations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):, At time of inspection tank appeared to be in good shape concrete baffels present no sign of back up.Recomend pumping tank. Grease Trap(locate on site plan): Depth below grade: t feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑-polyethylene ❑ other(explain): Dimensions: 'Scum thickness Distance from`top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 . Commonwealth of Massachusetts + W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form.-Not for'Voluntary Assessments °M 64 Maushop Ave. Property Address Howard Richardson ' Owner Owner's Name r information is a Barnstable Villa Ma 02668 7/11/11 required for every . g page. Cityrrown State Zip Code` Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene- ❑ other(explain):, Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: • ❑ Yes ❑ ,No Alarm level: Alarm in working order: ❑ Yes ❑ ,No Date of last pumping: bate Comments(condition of alarm and float switches, etc.):: "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11,of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °M 64 Maushop Ave. Property Address Howard Richardson = Owner Owner's Name information is Barnstable Village Ma 02668 7/11/11 required for every g - page. Cityrrown State Zip Code Date of Inspection- D. System Information.(cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert .- . 0 ,' = Comments (note if box is level and distribution to outlets equal, any evidence•of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in good working order no sign of carryover or leakage.Recomend installing riser. Pump Chamber(locate on site plan)` Pumps in working order. • . 0. Yes,.' ❑ No Alarms in working order: S • ❑ 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);• b If SAS not located, explain why:• - t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 64 Maushop Ave. Property Address ; Howard Richardson. Owner Owner's Name information is Barnstable Village Ma 02668 7/11/11 required for every 9 ' page. Cityrrown State Zip Code Date of Inspection- D. System Information (cont.) , Type: ® leaching pits number: - ❑ leaching chambers number.' ❑ leaching galleries number: ❑ leaching trenches ' number, length`: ❑ leaching fields _ number, dimensions: ❑' overflow cesspool number.' ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil; signs of hydraulic failure, levefof ponding, damp soil, condition of - vegetation, etc.): At time of inspection leaching appeared to be in working order no sign of staining or hydraulic failure.Water level was 4'5" below invert at time of inspection. w . f 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 R • Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes El No , t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 ` , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not,for.Voluntary Assessments,' °M 64 Maushop Ave. t Property Address Howard Richardson Owner . Owner's Name information is Barnstable Village Ma 02668 ,7/11/11 ' required for every ` 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.): a Privy(locate on,site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;' etc.): t5ins•09/08 Title 5 Offidal Inspection Form.Subsurface Sewage Dis posal bsal System Page 14 of 17 5 ` f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' ^M 64 Maushop Ave. Property Address Howard Richardson `" t Owner Owner's Name information is Barnstable Village Ma 02668 7/11/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below = ;. ❑ drawing attached separately X2 t } • (1 AQ_A6t.( t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 115 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 64 Maushop Ave. ' Property Address _ Howard Richardson Owner Owner's Name t information is Barnstable Village Ma_ 02668 7/11/11 required for every g - page. Citylrown State Zip Code "Date of Inspection D. System Information-(cont.) Site Exam: ® Check Slope r ® Surface water ® Check cellar ` Shallow wells ` >12 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: , t You must describe how you established'the high ground water elevation: r •. , - . a Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts' H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 64 Maushop Ave. Property Address Howard Richardson Owner Owner's Name information is g required for every Barnstable Village Ma 02668 7/11/11 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or.E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed' ® System Information— Estimated depth to high groundwater ® Sketch of Sewage,Disposal System either drawn on page 15 or attached in separate file 1 r ! .r • .. it t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION eW / y\ by! TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �G Property Address: 64 Maushop Avenue Barnstable MA 02630 Owner's Name: Howard P. Richardson Owner's Address: Same Date of Inspection: July 21,2006 Job#06-201 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 'I Telephone Number: 508-428-1779 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 mj,'j training and experience in the proper function and maintenance of on site sewage disposal systems.I ain a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: `��oaceocC III�j��� _X_ Passes Conditionally Passes ATHI K % N Needs Further Evaluation by the Local Approving Authority _ ,m_ Fails 0 *• 0' 0 • E •-{� • .y_ Inspector's Signature: Date: 7/21/06 '�,, Q • 'k`� 1NSP�G��O�``` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Vbtttt� 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: One leaching pit has never been more than half full,recommend pumping tank. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 Maushop Avenue, Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 I Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. ' The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 Maushop Avenue, Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 Maushop Avenue, Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 64 Maushop Avenue, Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period ? I _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site _X_ _ 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? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 64 Maushop Avenue, Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents:2 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): Two years total: 76,000 gal.=104 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL. Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank has never been pumped. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance 7/19/79 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 Maushop Avenue, Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 BUILDING SEWER: XX (locate on site plan) Depth below grade: 8' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 7' Material of construction:_X_concrete_metal_fiberglass__polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5'long x 5.8'wide—1500 gal. Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Distances to outlet baffle could not be measured,risers only over inlet end of tank Baffles are intact and liquid level is at bottom of outlet invert.Recommend pumping tank at this time and every three years GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 Maushop Avenue,Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 Maushop Avenue, Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: Two 6x6 pits. _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.): One leaching pit was nearly empty at time of inspection and had never been more than half full Other pit is located under buried utility lines and was not excavated CESSPOOLS: No (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: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 Maushop Avenue,Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Maushop Avenue Water Service 5 48 34 45 3 39 4 t' I Page 1 I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 Maushop Avenue, Barnstable Owner's Name: Howard P.Richardson Date of Inspection: July 21,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.25 and topo map shows property at or above el.80. L l G Gig-P V\ TOWN OF BARNSTABLE;r,OCATION 61,0 1w09 jOut- SEWAGE#�h5F ?.TILLAGE rR5V-,bQ ASSESSOR'S MAP&PARCEL aVJ l O' 6 S NAME&PHONE NO'�r%N ie Olc o nykkc j LQ6- I'll SEPTIC TANK CAPACITY %S—a0 SA LEACHING FACILITY: (type) Qi t5 (size) 1ti0C. NO. OF BEDROOMS�- OWNER �`�/ 1�i'�•I�a Sc3 f1 PERMIT DATE: �F DATE: —7(al/0(0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY - - —- • i ty K t� Mausho Avenue Water Service �3Y 5 48 • 45 34 �3 4 39` it` 'pJ''i>ci'23t ,A. LOCATION SENIA CE PERMIT NO. L L A G E �� yt INSTA LLER'S NAME & - ADDRESS B UlLDE R OR OWNER /�� DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �y ^---- 39 TOWN,O B;RNSTABLE LOC1 '�IQI�i: � ai.t sy D � swACE.#k VILLAGE. c4fn $7�i�l ' T °ASSIrSSt}f�'S MAY ci IL _ Cf jl,T Tt LLER 1�IAl &i'IitTPdE Y O ' SEP'C TANK I�tO �BED11 t�OIYfS B Id1 t iM OR o rm PERfi&>�➢�AT� CC3�$PLfsik�T� Sepaxat�an Ijzstar►ce�etw.,en�c �� dusted roundcvater'TA to the Bottom of Leachin Eaciiit Feet' Maxitum A.1 it Y Pnvate­E►at€r SupPiY: el audIaclug FaalanY (f€ar,Yres exist on sits or wathiir 2t1t1 fact sDf les tvn8 Y) feet; Edge oftetladd an st. with 3(�fee o/€`teach fl�tyjp t e )~UT d$hed by, 4ui .R { No.14k...... Fss... s�. .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ..............OF...............................--.--- ----------------•---•--------------•---•-•----_---- s Apphration for Uigpwial Works Tongtrnstinn Frrutit Application is hereby made for a Permit to Construct (") or Repair ( } an Individual Sewage Disposal Syst at.. � i9 J ` �`� ...... ,� i�oJ Ste • ' --•.............:. � --- Location-Address s, or Lot No. ..LJfG.... ^�f....---.lr!ll.. .T��r. .r -------------- ------------•-••-----------•--------••----•------____._--_----•--••----------_____---_--__-_-- Address W ' _ ..................•----......--------•-•- Installe Address/ l U Type of Building Size Lot_Z! �__Sq. feet Dwelling—No. of Bedrooms... �_______________________________Expansion Attic '( ) Garbage Grinder ( ) PA Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria a' Other fixtures ______________________ _ _ `{ W Design Flo......... _______________��___pp--gallor>s peAj"*` r3 per day. Total daily flow.___:___.._ _.____.a.................gal j s. WSeptic Tank—Liquid capacit.... lons Length_1__a_..____ Width__ __-______ Diameter................ Depth__j�__�__........ x Disposal Trench—No_____________________ Width.................... Total Length.................._�Total leaching area....................sq. ft. Seepage Pit No.........'�._-.-_____ Diameter._/ !.�., Depth below inlet___ ._ ..... Total leaching area.�� Z Other Distribution box (cal Dosing tank ( ) ,.,/6C-S '-' Percolation Test Results Performed by....... .......L C ...... Date__ �l, y7_ .............. ,aa Test Pit No. 1_._.?r----minutes per inch Depth of Test Pit/.J�—_"____ Depth to ground water_.'vO.� Test Pit No. 2......�� ,�/ ____.minutes per inch Depth of Test Pitf' ____. Depth to ground water...___._.. __ __ O Description of Soil--_--_-_-------YB--1 2 g GCS^� �1i �`� •---- ............................. r W ----------------------- �� � ` ' �'7p.ai 6 -�`s �'�` ............... UNature of Repairs or Alterations—Answer when applicable----------------------------------------_....................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I i.i p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iyalled by the b1paj f health. ` Signed_°- - ----- •-- ... _..._ /C Date Application Approved By..........;.-.- -/• ••-•-•-•---•--------------•-----•---------•--------------•--•......_...---- J__ Date Application Disapproved for the following reasons:................................................................................................................ Date t PermitNo.........o �................................... Issued_......-1_-• 1--1------•-=-------------•---•---- Date No......... FE:B.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® gF,'HEALTH r... - ......OF........ 2:- .�t-..�: -0-4.1e Appliratiun fur Uhipoii al Works Tunitrnrtiun Vamit Application is hereby made for a Permit to Construct (Ploor Repair ( ) an Individual Sewage Disposal System r� Location-Address or Lot No. ••••-•-----••---••-•-__-- --•-••-------- -•----------------------------•--- Owner Address w /o�c-kT ,. Installer Address Type of Building Size Lot___� ...................Sq. feet Dwelling—No. of Bedrooms.............................................Expansion >ic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.....,___ -___________ Showers ( ) — Cafeteria ( ) Otherfixtures cY ---------------------------------------- ------------------------- W Design Flow......................__ .........gallons per ge:sen per day. Total daily flow.___._._._________�_�_ __.........gallons. WSeptic Tank—Liquid capacity/ gallons Length..... Width....A/....... Diameter________________ Depth_____4-1...... x Disposal Trench= No_____________________ Width......._............ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........r........ Diameter____________________ Depth below inlet-----C. ........ Total leaching area2_4K_j1r'._.sq. ft. Z Other Distribution box ( Dosing t ( ) ~" Percolation Test Results Performed by.....k!_I._'__A _C.. ..................................... Date.... .......... 1`44 Test Pit No. lltFy..minutes per inch Depth of Test Pit____________________ Depth to ground water........................ 44 Test Pit No. 2._j ......___minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Description of Soil j -•�� -----••-••.''•ix--••••- - �' 4-----------------------------------------------------------__-- x -------------------- W UNature of Repairs or Alterations—Answer when applicable______________________________________________________________________________________________ - -- --•••-------•-••-••••••••-•••---•-•-•-•-••---••••••-••••-••••-•--•--•---•-••••....••••-••••••-----•---••-••-•••-••••--•• ••••••-•-••--••••--•-••--••---•••••••....• -----......••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITHE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued y the board of health. Signed 1 I� . ----------•-•-•• ................................ Date Application Approved By------------- ...._ :�1' ' _______..-..._......... . Date Application Disapproved for t following reasons: ............................-•-•••••--••--•--•••••--•-•--•-••-•---•--•---•••••••-•-•----•-••--•••-••---•--••••••••--•••--••-•-•-••-•---••••••-••-•-•------•••••-•••----••••--••-----•••••-•---••-------- Date Permit No....-- •-•-----------------------------------= Issued_......S........311 e 7 Date J,------------------------- Fimz............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA ,TLJ _..----...-:OF........ ............. ...................................... Appliration for Disposal Works Touistrurtion vrrmit Application is hereby made for a Permit to Construct ( or Repair an Individual Sewage Disposal �CS' ystetn t. ......................................... ............................................................................................ Location-tAddr —1, or Lot No. ;ys C 0'J ................... .................. ... -------------------------------------------------------------------- Owner -;; Address ....................................................... ........................................................................... Address Type Acui/Kdring"' Size Lot...... ......6........Sq. feet U Dwelling—No. of Bedrooms_________________ .........................Expansion tic Garbage Grinder ( Other—Type of Building ...................I......... No. of persons....... ......... Showers Cafeteria ( Otherfixtures ---------------------------------ee64�1.......................................................77.. .............................. < Design Flow_______________________'71,0..........gal ons per person per day. Total daily flow___.________.____........... ___.________gallons. W .......... 1:4 Septic Tank—Liquid capacity/�T'_�gallons,,. Dianieter................ Depth....15�....... Disposal Trench—No..................... Total Length.................... Total leaching area....................sq. ft. lameter--------------------- Depth below ir�fet .-I Total leaching area,2j!5'...4 r...sq. f t. Z Other Disiribution,box Dosing. tank Percolation Test Results Performed .....................................o........................ Date....:J................................. Test Pit No 1/' -minutes per inch Depth of/Test Pit.................... Depth to ground water........................ _Z __minutes per inch e �T4 Test Pit No. 2.A nii Depth of"Test Pit________________....Depth to ground water........................ .................................................. ---------- ----------*-----------*---------------- --------0*--------------.................. 0 Description of Soil-------------- e........ .........IX--el....... .................................... ................................... U ........................................................................................................................................................................................................ W '!., ....................... ................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applkabie.............................................................................................. .................................................................:..........................................................................................................................._.- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T 1Z 5 of the State Sanitary Code—The undersigned'further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 2, I's ........................... ................ Date Application Approved BY--_--q.en 4. opsAe! ................. .. ..................... ................... ---------------------------- Date Application Disapproved f the following reasons:................................. ..................................................... .................... X ......................................................................................I.................... ...............................f.............................................................. Date Issued...... .......... Permit N&.7A.1........................................7— Iss *3......7V..................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F.................................................................................................... .0 ............... (Inti iratr of Toutplianir THIS IS TO CERTIFY, That the Individual Sewage Dispos7alSystern constructed or Repaired by------------------*'*..........AV 611-4 r 0104 ......................................................................................... y .......................................................................... Installer tip/ir AM Y, A e 4 at--------------------.................................................................................................................................................................................. has been installed in accordance with the provisions of TITLE; 5 of The State Sanitary Code as describ-cd in the application for Disposal Works Construction Permit No__ ......................... dated---- ------- -------- ...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUAJtANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE__...__... 'Z 2........... .......................... .... ---------- ......Inspector ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFHEALTH 146, .................................OF..... ................................................ s 'No......................... FEE........................ Disposal Workii Tonstartion Permission is hereby granted.......n........... G 6L --•---------••--•--•---•---•---•-_..... --••...................................................... to Construct or Repair an Individual Sewage Disposal System *Yh, h at No.. ... 4_r.e�........// ....................... ................. _e------------- ......................................................................... 44 Street as; shown g Disposal Works Construed the application for Dis on 'Permit No------1-0.1----- Dated-----------in L.14 .-7........ ....................................... ------------------------------------ D/erE�6V Board of Health­:ZZI...................................... . .... FORM 1255 HO WARREN. INC., PUBLISHERS i,7_;13c b 4-1 12 PfT DiST.. BOX '- /JOka O GC}L t �1 a T.ti tv i< a /3 A 1 �� "W a 1 r is 1' i o ... .. _ ', � �Y}-�. - i+ �S,LT�:�".' �ax �• y� }3;r �L \. ,1, s t L _ - �� V, 4` S. _' t 4��.i. r •+ :j, -7.SOU..407 -r•4 .. y.Y () /1 I .l - �•' Y 9�'�I 1 f✓'�T' do .3 ",s- r <(tl'UF P ti\ate t t 0.9EPT i l f i?s ' O�FSS,lONALE� t � .,: _ •` it LEGEND ti! EXISTING- SPOT ELEVATION Oz0' CERTIFIED PLOT ' PLAN � EXISTING CONTOUR 0 wax / ,A ct i-F70 -1 N. B'I°NYSNED S-POT 1 ELEVA r i p-N-t 0"G f�FINISHED CONTOUR CONTOUR 04✓N_/S/�G�R;? _ r` , APPROVED : BOARD ` OF HEALTH. DATE — AGENT -- =- SCALE:�'���=- 30 'DATE S�ZS 7 r LORE®GE ENGINEERING CO.ING� t�A o ., f CLIENT _-- I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED �pB Np 7 '03,4—. BUILDING SMGWN ON THIS PLAN - CIVIL LA CONFOR`AA$ PTO. THE ZONING. LAWS' DR. t?• A' tl; EY�GINEEI4 SU_RVEYOft — OF BARN:S.TA, E MA 33 NO MAIN ST 712 MAIN—ST CH. BY /7� { fi M •! .3 SO. YARMOUTH MASS. HYANNIS MASS. — ' SHEET OF DA „ :D �E REG. LAND SURVEY'Oktr TANK DR _ P/T, 4RE >:MORE T•y�1,"✓ ./2..BEL. _ t k.4.l7EI fi 2¢"O/AM ET.ER :CONCA� TLE COKE. /D FT. M/A/ , x 1 SNAL4 BE /9ROUCaHT PTO 61�ADE �i+/✓ E�'7"RA ' _ t. .� 4. ` € 4 PVC P/P� r• <, �F NEAV)/.C/4'ST IRON CD✓ER Sf�/�L L ,C3E Z/SEU '611 CONCRb'TE M/N:'P/TCN 3.0 .CODERS i Y F�`cR FT �C7R/VEN/A =� f •CD/VC&.E TE 9 r a i/i `r-- �- \ --- d— l-- 4R•9 O E C U 1 ER C L EA/V _3,A N,C;l A _Tfi i i RACKET LL _ 2 LAYER B, ja 4 Cq S T OF",�8 IRON PIPE ' U /.O U.I OJ GAL'. ° o e e •' • •.. • e e M of m4 5,HFD STONE � � - WA Ua U/ST, ° • • • • e e • u f J I _pTlC ANk J, I �: -nt a-i •. p.0 oal - T 14 A� Box g 1 e a r • • DEPTH ° • e 'j• `gym I wA5HE0 57,QNE n Z e e • • s • s • 1 pry o o r - I ' `c° o e ei • e • • . • e P — 0i?EC-A.5 T SEEPAG.E„ a L C o� c*m `a ! r. • •j • o s e • e ' z �' �ej' P/7 &R EQLJ1L a o r e n • • . • • • e e a, oI M c� y 92 J /LAYER T AT BU/LU/NG FT.. r• - --- ---- ---- :C SEE T<,1411- 7-)0 v FT. YV/Xl!� INLET SEPTIC TA/VK '—ULL FT OUTLET SEPTIC TANK _ 3 FT• K TABLE , GRDuNv HltlTE /NLE7 G/STK/tgUT/ON' `SOX SECT/ON 4F I OUTLE:%D/STR/BUT/U/V BOX�8.9 FT l3/.SP��A L .S`Y.�T�M I /LACE r [EACH/LAG ���- e s Fr. .�Ed�tI�GE T�I�ULf9TlDN /LAG P/"T ' r L EACH znMEN!S10 N AT. ; SCALE %4 _ _ DESIGN CKITER/A /:' D pIM.EN>/oN. $ FT. I FT. •"✓ , NUMBER OF 3 Y LpG _ L T .SD/L' f). L TES ! CsARtlAvE DISPOSA ,1N _ 33 � r TOTA4 -5T/MATED A LOPV-__--___GAG IDAY".50/L .TEST / SOIL TESTgdt2 I IVUMdEiP GF .-a�At:IIINGi BITS_ .. +- ELEI! !0 0,0 SATE OF SO/rL TEST•,___s/ 'f7 -- / Ff �f� " '� RESUtTS v�//TRESSED BY S/OE LEACH/LAG PEft P/T — _ .._ SQ,. FT_, 6CUTT0M LC-�4CN/LAG PER l�/r_ SQ- FT L t' A /' 1 TOTAL LEACH/LAG AREA 2G 6;s4 .F.T. r /Y Y l�E�coc�TiaN R,4TE.,12 RESERVE LEACHI/VG AREA-_'_-6 G_S4. S / I - ------ r N L-f►n/C li ,.: p - . s . k NG/NEER/NG CO. //v4c :'BUNtK�s ELOREDGE eE , tit '� F Wa.22162 O T ND, MAI/v ST w o PF a41 ��� A s� +; Let/ B�,C k i t 772 MAIN ST 33 '. / NY'QNIV MASS SO. YA.RMOUTN�Mtls� 11 F, G /ONAL�6\•� rXj NO GI�OUNl7 YYATEf:' ENCOUNTE. �O s+ate :' —. G L7 yv TER /i T Ez-AV r 9 0 3 SHEET OF Z- A � a No:.... d....,,, FEB... ....:,� .. -, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ---------------- ---- ....................OF.........................-----.......... :. Appliratio n for Uh4posal Works Tonstrurtion "trait `A`3 ication is hereby made for a Permit to Construct (' Repair ( ) an Individual Sewage'Disposal Systems at: ___ ......................... ....-- Location•Address or Lot No. w. w r Address Wf ' •-•----•-- ......------•---••-•---........ Installe Address UType of Building , �' Size Lot__ ;x j:_-ZZ___-_..Sq. feet Dwelling—No. of Bedrooms.......... `_______________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures - =---- --------- ----------------------------•--------- W Design Flow.......�'.�`._ _.._...... gallons per.pe;�� per day Total daily flow------------ _ ?.................gallons. xSeptic Tank—Liquid capacity/4&gallons Length__ Width .......... Diameter................ Depth_;�..._:�.. . Disposal Trench—No..................... Width ___-- Totai Length . Total leaching area....................sq. ft. Seepage Pit No..._____Z-_______._ Diameter %' ..._ __p Depth below inlet__-' g ":— . q._____ Total leaching areal .s f.. z Other Distribution box ( Dosing tank Z 7"' a Percolation Test Results Performed by------- ....... �,,J_ _ _ ...... Date___'; _._....._... . a Test Pit No. I..... ....minutes per inch Depth of Test Pit/ .`...... Depth to ground ri, Test Pit No. 2-----—.__._minutes per inch Depth of Test Piv_X/___...... Depth to ground water...................... 5 Rai Z•'---/...... -=•=- `�•------.... �_:.z---' ................................................................ -O Description of Soil.....................�f U .. . - --, -- - ------ - ° - r r"a -4 . UNature of Repairs or Alterations—Answer when applicable............... . .. .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT LE,p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the by r health. Signed'- � --------•--•--------- jy ±1 - T APPlication Approved BYDate ............. - .--7t,---- Date Application Disapproved for the following reasons-------------------------------------------------------------------•---- ........................................ .....................................-..........................................................-------•-----•----•-------------•------•--••---•---....------------------......---- ........._.... Date PermitNo.---.....JA U--•-•------•-------•--.....----•-_. Issued........................................................ Date- - THE`COMMONWEALTH OF MASSACHUSETTS BOARD OF ALTH .. OF................... . ... THIS IS TO CERTIF „ That td: i ual Sewage Disposal System constructed ( ) or Repaired ( ) by ..... ------------------•------•---------•-----................---•-•-------............._..._----•----•---- Installer at•----•--•-.. �7� uaS6P C ! i_�:'_r . -.. has been installed in accordance with the provisions of TIT13 j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._ __:2v......................... dated__ ............. THE THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.. J DATE.....5 / 7 Inspector ! -••---•--•-•---•-•••-------...` .. ---- 3 {i "'"4�` `x.�l R,�• ^.�+.7' . "sst�j�' :e.'.'#, t k THE COMMONWEALTH OF MASSACHUSETTS BOARD Qg0 4+° IEALTH .. .. �f No....J_ 5 •....... FEE.....n!:A....r r Dig os Works Toft rr rrmit Permission is hereby granted.. -- - ------------------------------------- ......... F to Construct (,4 ) or Repair ( ) an In Idual Sewage Dis al System at No.............1--ep-� ........fir U_ di lr.e��!�.....---'�a Street as shown on the application"4,oPD`isposal Works Congtiuc I mit No.._-.:_.mP.f!....... Dated-_. �r__-jG f - ` _ •_ Board off Health DATE........ --• ••---•-•---••-----•---•--•------- FORM. 1255 HOBBS;&„WARREN, INC., PUBLISHERS r ss r - _ �- T M _ _ _— — —o —o—o—o— proposes/ c�rou-col Pro f/ /e S c H E O. 4 o A-7 V c O,2 — F L o tom/ EQUAL- To SEPT/c-K m,ni/Tfvm of�� - �2 washed stone 71/v i 51 AZI Lei • 47 ICI)/Sr BOX G _d:a. 6" Sump • ; L `. I . • n , c G/9L. 6 P7- TANK -— --- 14 tv Q S f7 s d S O/7 C • • f • • y SCALE: 3 { gar � S / G o / o r,/ �, T E L rs vs e; 1 F'E E' c E' 7 f= G /t,7/N.//AJ C/-Y GtJ/T AJ E 5 S !�U C. /�cl `J'` o e/"7 440 G 9G5.l0'9 tl w ;t *. 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