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Home My WebLink About0250 OLD JAIL LANE - Health f e } ar Bamstable .. • t=.._. Commonwealth of Massachusetts /P 2__ w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 250 Old jail In Property Address u Lawrence Stenzel Owner Owner's Name information is Barnstable V Ma _02630 7/16/15 required for every _ Fv.» page. City/Town State Zip Code Date of Inspection F+ lw . Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Company Name 8 Johns path Company Address S Yarmouth _ MA _ 02664 _ City/Town State Zip Code 508-364-9587 _ S113522 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 7/20/15 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. V� 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 250 Old d jail In Property Address Lawrence Stenzel Owner Owner's Name information is Barnstable Ma 02630 7/16/15 required for every _ page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/a/ways 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: The system contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. 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): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 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): ❑ 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. A. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ 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•3113, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Ins pection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name --- information is required for every Barnstable Ma 02630 7/16/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This.system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: s You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Foam Isl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 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 ❑ a 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. ti t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Z ❑ 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 15ins•303 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 250 Old jail In �M Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 page. CitylTown State Zip Code Date of Inspection D. System Information Description: The system contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. Number of current residents: Does residence have a•garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available last 2 years usa e d 172 Gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 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: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site glass on truck 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•3/13 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 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 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: 13 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 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.): System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: 1 ftfeet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 150.0 Gallon Sludge depth: 31 t5ins•3/1.3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 250 Old jail In Property Address Lawrence Stenzel Owner wn r'• e s Name information is required for every Barnstable Ma 02630 7/16/15 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was pumped at time of inspection as well as on a regular basis. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 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.): Tank was pumped at time of inspection.as well as on a regular basis. Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material'of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ 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 15ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 17 A. Y- ,.'pe' vr•.,Gy ,iS zMp,x yfd �:` i Y' .�A.`, '•l oft i " ,'r� Commonwealth of Massachusetts u W Title 5 Official Inspection Form =� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c< ^M a 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 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 At normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution Box is level and at normal level with no signs of carry over or decay. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurfape Sewage Disposal System Form - Not for Voluntary Assessments 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 page. City/Town State Zip Code - Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 500 g I ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of carry over'and no signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is Barnstable Ma 02630 7/16/15 required for 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.): No signs of ponding or hydraulic failure. 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.): I 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 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630. 7/16/15 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 + ft feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: July 02 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan indicates NGE at 12 FT Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 250 Old jail In Property Address Lawrence Stenzel Owner Owner's Name information is required for every Barnstable Ma 02630 7/16/15 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LOCATION�5~a Olt J A�,\L etc SEWAGE ii r2d `C-Q s 1 VILLAGE- Alin W L ASSESSOR'S MAP&LOT )-7ff-049-0o ME 1 INSTALLER'S NA &PHONE NO. ° 10-C'Q L Lc►-- L4 7S— —4 SEPTIC TANK CAPACITY / C)Q 6 &U0 A LEACHING FACMrIY: (type) SOO 6gl/n �`'�--�'----(size) `lob NO.OF BEDROOMS '1. BUILDER OR dWNER OC-� iZA -^�00\0 PERMITDATE: COMPLIANCE DATE: 30 D 2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wellsv.ezist 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 Furrushed by 1 feA2aGa 30 f� VL C! � ~ ocrT�c..� -�26 /6 . 01 J GV "t Commonwealth of Massachusetts - F Title 5 Official Inspection Form' a Subsurface-Sewage Disposal System Form -Not for Voluntary Assessments 250.0Id Jail Lane, Barnstable M,-278 P -49-002 Property Address -- Michelle Galvin' Owner Owner's Name ------ —. ---------- ----------- --- require tion ie Barnstable MA 02630 September 22, 2009 ..required for every — p — 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. S!41 Important:When A. General Information filling out forms on the computer,use only the tab 1. inS eCtOr: 0 Q PY key to move your p cursor-do not Tr0 Williams use the return -y--- - - . — key. Name of Inspector TroyWilliams Septic Inspections rab Company Name 19 Hummel Drive Company Address --- ----------------- - South Dennis_ ^_—_ __ MA 02660 Cityrrown State.. Zip Code (508)385-1300 S1682 _ 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 d�J^ September 22, 2009 Inspector's Signa re 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.. 250 Old Jail Lane,6arnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage pispo, I System•Page 1 of 15 Commonwealth of.Massachusetts u _ Title 5. Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0 250 Old Jail Lane, Barnstable M -278 P -49-002 Property Address - -- .y ' -------------- -- —,-- --- Michelle Galvin Owner Owner's Name— - ; ; — -q -------- --- ------ - ---- information is Barnstable MA 02630• September 22 2009 required for every —_ -- _ _ _�_—_� _ page. City/Town, State Zip Code, y Date of Inspection f . B.'Cilrtification (cont) - , ti Inspection Summary: Check A,B,C,D or.E/always complete all of Section b A) System Passes: 4 w have not found any information which indicates that-any of the failure criteria described in 310 CMR 15:303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.',,. ; Comments: System meets minimum standards set by Mass DEP at the time of inspection only. This inspection.is " not a guarantee or warrantV on the future working conditions of leaching, ipes or components. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The systein,.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 El for the following,statements.'If"not determined," please explain. ❑ The septic tank is metal and over20 years old" or the`septic tank (whether metal or.not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. ` System will pass inspection if the existing tank is replaced•with a complying septic tank as approved,by the.Board of Health. ' " A metal septic tank will pass inspection if it is structurally sound. not leaking and if a Certificate of Compliance indicating that the tank is,less.than 20 years old is available. ND Explain: N/A Observation of sewage backup orbreak,out or high static water level in the distribution box due to.broken or.obstructed pipe(s)or due to a broken„settled or uneven distribution box. System will pass inspection if,(with approval of Board of Health): El broken pipe(s) are replaced 0 - obstruction.is removed 250 Old Jail Lane,Barnstable•03108. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 i Commonwealth of Massachusetts u W Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 250 Old Jail Lane, Barnstable_ M -278 P -49-002 Property Address — — --- — --- — --- Michelle Galvin Owner Owner's Name ---- require tion is Barnstable _ _MA 02630- _ Se ember 22, 2009 ..required for every _ -- p _ page. Cityfrown State Zip Code Date.of Inspection B. Certification (cont.) . B) System Conditionally Passes (cost.): . ❑ distribution box.is leveled or replaced ND Explain: ' N/A ❑ The system required pumping more than 4 times a year due to brokenor obstructed pipe(s). The system will.pass inspection if(with approval of the Board of Health). ❑ broken pipes) are replaced . ❑ obstruction is removed ND Explain:. N/A C) Further Evaluation is Required by the Board of Health: ❑ .Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. . 1. System will pass uniless Board of.Health determines in accordance with 310 MR. 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:ofa 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. 250 Old Jail Lane,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Corr JSubsurface Sewage Disposal System Form.-Not'fo,r Voluntary Assessments 250 Old Jail Lane, Barnstable _ M-278 P -49-002 Property Address — -- Michelle Galvin - ------- == ------- -- - Owner Owner's Name — information is required for every Barnstable MA 02630 September 22, 2009 page. CityfFown State Zip Code. ..Date Of Inspection B. Certification (cont.) - C) Further Evaluation.is Required by the Board of Health(cont.): ❑ The system tias 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: N/A *" This system passes if the well water analysis, performed at a,DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A D) +System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each ofthe following for all inspections: Yes No' d ® 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 0 ® or.clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6".below invert or available volume is less than %day flow Required pumping more than 4+times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: , E] .® Any portion of the SAS, cesspool or privy is below high groundwater elevation. El M. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 250 Old Jail Lane,Barnstable-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments ^M 250 Old_Jail Lane, Barnstable M -278 P -49-002 'Property Address _— Michelle Galvin Owner Owner's Name information is � p for eve required Barnstable MA 02630 September 22 2009 . _ 4 - wn page. Ci ty,'To State .Zip Code'. Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to AII.Systems (cont.): Yes No 1z Any portion of a cesspool or privy is within a Zone 1 of a public well. I] M 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 15,00.0 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 ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—:IWPA) or a mapped Zone 11 of a public water supply well If you have answered"yes"to.any question in Section E the system is considered a significant threat, Or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 250 Old Jail Lane,Barnstable.•03/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 15 Commonwealth of Massachusetts Title 5 Officia!l Inspection Form'' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 250 Old Jail Lane, Barnstable M -278 P -49-002 Property Address — -- Michelle Galvin Owner Owner's Name information is p required for every Barnstable MA 02630 September 22,2009 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the.,following have been done.You must indicate:"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,,occupant; or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? �' ❑ Has the system received normal flows in the previous two week period? ❑ ° ® Have large volumes of water been introduced to the system recently or as part of this inspection? 0 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? M. •❑ Was the.site inspected for signs of break out? :' ❑ Were all system.components, excluding the SAS, located oh 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 ®3 information on the proper.maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the sitehas 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)] i 250 Old Jail Lane,Ba`r`ilstable•03108.' �;. 'Title 5 Officiat Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 250 Old Jail Lane, Barnstable M -278 P 49-002 Property Address Michelle Galvin Owner Owner's Name --- information is Barnstable MA 02630 September 22,2009 required for every —� page. Citylrown State Zip Code Date of Inspection D. System Information r 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).- 4-40 gpd Number'of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑-:Yes M No Water.meter readings, if available last 2 ears usage (gpd)), 08=192,000gals 9 ( Y 9 09= 32,000gals Sump pump? ❑ Yes M No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A N/A Design flow(based on.310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ® 'No Industrial waste holding tank present? ❑..Yes ® No Non-sanitary waste discharged to the Title 5.system? ❑ Yes ® No Water meter readings, if available: N/A Last date of occupancy/use N/A . Date Other(describe): N/A — . 250 Old Jail Lane,Bai518table-W108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Page 7 of 15 f Commonwealth of Massachusetts Title` 5 Official Ihspecti®n Farm` Subsurface Sewage Disposal System.Form -'Not for Voluntary Assessments ti 250 Old Jail Lane, Barnstable M-278 P -'49-002 Property Address Michelle Galvin Owner Owner's Name information i e required for every Barnstable MA 02630 September 22, 2009 — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information . Pumping Records: No pum�in Ig nfo is.availabl�e. Source of information: -- - Was system pumped as part of the inspection? ❑;Yes ® No If yes, volume pumped: N/A' gallons How was quantity pumped determined? N/A Reason for pumping: a -- -- 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 sysfem'owner) and a copy of latest inspection of the 1/A system by system operator under.contract ,- w ❑ Tight tank.Attach a copy of the DEP approval. f � ❑ . Other'(describe): Approximate age of all components, date installed (if known) and source of information: Tank,d-box& Ieachin were installed on 7/30/02_pje compliance. Were sewage odors detected.when arriving'at the site? b ❑ Yes ® No 250 OlQ Jail Lane.Bailtttable 03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 s' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 250 Old Jail Lane, Barnstable M =278 P 49-002 Property Address -- ---- Michelle Galvin Owner Owner's Name ----- information is Barnstable MA 02630- September 22, 2009 required for every _ —.__ �— _.— .page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) Building Sewer(locate on site plan): Depth below grade: 18"+ -- feet Material of construction: 0 cast iron ® 40 PVC ❑ other(explain):: N/A 'Distance from private water supply well or suction line:: feet Comments (on condition.of joints, venting, evidence of leakage, etc.)`. Flushed lines and found clear atthe time of inspection Some grease was found in main line from home' Septic Tank (locate on site plan): : Depth below grade. feet Material of construction. ` ® concrete _ ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age". N/A years Is age confirmed by a Certificate.of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: , 6'X 10.5'X 6' 1500,gallon s Sludge depth: 4,, Distance from top of sludge to bottom of outlet tee or.baffle, --- -- 6,, 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 8 -- How were dimensions determined? Probe Measured 250 Old Jail Lane.Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection For m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 250 Old Jail Lane, Barnstable M -278 P. -49.-002. Property Address Michelle Galvin Owner Owner's Name -- information is p required for very Barnstable MA 02630 Se tember22, 2009 e — page. CitylTown 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.) Pvc inlet and outlet tee's were present. No.evidence of.leakage or damage was found:Tank was in need'of pumping at this time. Soniie grease was present in tank. Grease Trap(locate on site plan): Depth below grade' . N/A feet Material of construction:. ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A N/A Dimensions: — Scum thickness N/A __ ----- Distance from top of.scum to top of outlet_tee or.baffle Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date Comments (on pumping recommendations,inlet and outlet tee or,baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight'or'Holding Tank(tank must be pumped at time of,inspection) (locate on site plan): Depth below grade: N/A -- -- Materialof construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain).- 250 Old Jail Lane,Barnstable r 0310E Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments °M 250 Old Jail Lane, Barnstable M -278 P-49-002 Property Address — — Michelle Galvin Owner Owner's Name information is required for every Barnstable MA 02630 September 22, 2009 page. City/Town State. Zip Code _. Date of Inspection , D. System Information (cont.) Tight or Holding Tank(cont:) Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑' Yes ❑ No Alarm level: N/A ----- Alarm in working order: ❑:Yes ❑ No N/A Date of last pumping: Date Comments(condition of alarm and float switches, etc.): N/A Attach copy of current'pumping contract(required). Is copy•attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site.plan): Depth of liquid level above,outlet invert Level with Comments (note if box is level and distribution:to outlets equal, any evidence of solids carryover,any evidence of leakage..into or out of box,etc.): b-box was found clean, level and in working order with equal:distibution to outlet lines through speed levelers.: Pump Chamber(locate on site plan): Pumps.in working order: ❑ Yes ❑ No Alarms in working order: [T Yes ❑ No 250 Old Jail Lane.Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface.Sewage Disposal, System Form -Not for Voluntary Assessments 250 Old Jail Lane, Barnstable M -278 P -49-002 Property Address: Michelle Galvin Owner Owner's Name -- information i e Barnstable MA 02630 Se tember 22, 2009 required for every _ ---_ _ _ _ page. City/Town State Zip Code Date of Inspection .D..System Information (cont.) Comments,(note condition;of pump chamber, condition of pumps and.appurtenances, etc.): ,. N/A- Soil . : . i Absorption System(SAS) (locate on site plan,.excavation not required): A. If SAS not located, explain why: N/A Type: Q . leaching pits number: - 44-500 gallon �. leaching chambers number: .• w/4' stone . Elleaching galleries, number; 12'.10"X 42'X 2' leaching trenches, number, length` --- — leaching fields number,dimensions: — — ❑ overflow cesspool` ;. number:. El innovative/alternative system Type/name of technology: =--= Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil;condition of vegetation,.etc.): Soil was sandy. Water level was low in chambers with no evidence of hydraulic failure or problems in the past found at the time of inspection. _ 250 Old Jail Lane,Barnstable•03108. Title S.Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 250 Old Jail Lane, Barnstable M 278 P 49-002 Property Address -- -- Michelle Galvin Owner Owner's Name information e. Barnstable MA 02630 September 22, 2009 required for every P page. Citylrown State Zip Code_ Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on,site plan)' Number and configuration N/A Depth—top of liquid to inlet invert N/A N/A Depth of solids layer Depth of scum layer N/A ,---- Dimensions of cesspool N/A Materials of construction N/A' Indication of groundwater inflow ❑ Yes ® No Comments(note condition of soil;-sign's of hydraulic failure, level of ponding, condition of vegetation,`, etc): N/A Privy (locate on site plan): } - Materials of construction: N/A _ N/A . Dimensions ----- - - Depth of solids N/A Comments(note condition of soil,.signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A 250 Old Jail Lane,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 " f , Commonwealth &Massachusetts . Title 5 Official Inspection F®rm Subsurface Sewage Disposal.System Form -Not for.Voluntary Assessments 250 Old Jail Lane, Barnstable M -278 P -49-002 Property Address - Michelle.Galvin Owner Owner's Name — information is required for every Barnstable MA 02630 September 22, 2009 �� page. City/Town State Zip Code Date of.inspection D. System Information (cont.') Sketch Of Sewage Disposal System; Provide a sketch of the sewage disposal system including ties to at least two permanent reference,landmarks or benchmarks: Locate all wells within 100 feet. Locate where public water supply enters the building. I f r O j2 l� O f 250 Old Jail lane,Barnstable•03/08 �' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 f - Commonwealth of Massachusetts z Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form-Not.for.Voluntary Assessments 250 Old Jail Lane, Barnstable _M -278 P -49 M2 Property Address --- — Michelle Galvin Owner - Owner's Name information is required for every Barnstable. MA ' 02630 September 22; 2009 page. Cityfrown State Zip Code Date of Inspection. D. System Information (Cont.) Site Exam: Check Slope ❑ Surface water , Check.cellac . ❑ Shallow wells Estimated depth to high ground water: 20.0' + 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- 12/21/01 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 USES database -,explain: MIW 29 Zone B 8.7' 3.0' adjustment. You must describe how you established the.high ground water elevation: Soil was sandy.Test hole 5.5' below bottom of leaching.with.no water found at 10,5'. Groundwater adjustment in'area at the.time of inspection.was 3.0'. Bottom of leaching at 5.0'was found not to be located in the high groundwater elevation at the.time.of inspection._, 250 Old Jail lane,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15.of 15 IT `3 A TOWN OF BARNSTABLE ECk-ATION.ol$�O ®40 1A�� oEMe. SEWAGE `2— ae( VILLA ASSESSOR'S MAP & LOT LDY940),. INSTALLER'S.NAME&PHONE NO.IB A`CL-CC-LL5�'-� La-5-ra SEPTIC TANK CAPACITY /,5-®Q (o LEACHING FACILITY: (type) -D®6°4A/4 (size) NO. OF BEDROOMS BUILDER OR OWNER ®�f°►2A � \� PERMIT DATE: �� --d �COMPLIANCE DATE: 36 2 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 iV eland and Leaching.Facility(If any wetlands exist within 30.0 feet.tlf leaching facility) Feet Furnished by fN (l� 0� � �� y � � . � � r � � � � � � e 'i o � _ c r— d k � �,1 1 ,� �1 � � - . - " . � J ,�A..__�.. � c'. �' s i � . ( � T . .� �,..- i r tJ+' d. ,., �t / No. )Ua 1—0�i'� Fee /� . THE QOMMONWEALTH OF MASSACHUSETTS Entered in computer: 'V Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for Diopool *pgtem Construction Permit Application for a Permit to Construct(✓SRepair( )Upgrade( )Abandon( ) ®Complete System ❑Individual Components Location Address or Lot No. LOT 3 A Owner's Name,Address and Tel.No. 2 vLD Assessor'sMap/Parcel L 7 !�c z- 1/1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 4 Lot Size 74 3—7 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �Z9. �' gallons per day. Calculated daily flow 440 gallons. Plan Date Tom/• Z9 Z 0C1 Z Number of sheets Revision Date Title -S/rL' p /N 0/z W- k/oaGG-/;/an Size of Septic Tank /'Sd o Type of C-14 136-n-r Description of Soil ��/2 Lath -S/I T/D Z'= 3L S/4w1>Y Z04 ML�Ij/ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by this and of Va. SignedDate X(I 4 30-c? Application Approved by ` - Date 0� 0 2 Application Disapproved for the following reasons Permit No. 2 b 0 ? ^0 Y.2 .., Date Issued 61 0 2- No U 0` r Fee �oU: " ' Entered in computer: It COMMONWEALIi OF MASSACHUSETTS _. y V - - PUBLIC HEALTH DLVISI}ON°=:,TOWN OF ARNSTABLEs MAS.SACHUSETTS :'•:; l�� ,plicatiou. for ig ogaY p�tenY �o.r��tructiott ermcit T Application•for a Permit to Construct(Vf kepair( . )Upgrade( )Abandon( ) ®Complete System O Individual Components Location Address or Lot No. L 0-r 3 A Owner's Name,Address and Tel.No. y>, r, Assessor's ap/Parcel �-7 y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. So HP) Type of Building: 3` 4 Dwelling No.of Bedrooms '` Lot Size 71 3 7 . sq.ft. Garbage Grinder( ) Other �. �Type of Building No.of Persons Showers( ) Cafeteria(, ) � 'Other Fixtures Design,Flow S"Z 9, ;gallons per day. Calculated daily flow "-fin gallons. Plan Date -1'-A A/• Z-9 Z 0V Number of sheets Revision Date Title `-�i�2- PL/7�r �.v �3,�liz,./STf+I�LL-` �v%Z �f�iw.R/,d/� W• �c/o%+lG.A/ZB r';' Size of Septic Tank /.Say.." Type of S.A. Heu G'44e.c,^1 lQ�c/-Ie1-14",3,e7Ts ` Description of Soil G /2" L v�s-i SAT/D a �=3� S/ D,y Ga�4 14 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: j= g �. A reement: The-undersigned agrees to ensure the construction and maintenance of'the afore'described on-site sewage disposal system a in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by this ,Yard of Hea / ` Signed Date�y I t 30~U Qq Application Approved by v- - Date Ui A :2 n Application Disapproved for the following reasons Permit No. 2001 ^O Y 2' Date Issued a 61 10 Z- -✓. --------------;f -- �---------A---------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by at 5d b f 3A D-I T� I Lve.c Q .� h�� has been constructed in ccoodance with the provisions of Title 5 and the for Disposal System Construction Permit No. �Grl 0`�� dated 2 n 6 Installer Designer The issuance of t 's peTnit shall not be construed as a guarantee that the syste ill func w s°de'sig e j,, Date "7 6 •_ Inspector . ----- t: ---------- ————— -- ------ -- — `No. 0u) UL/2 - -- Fee �U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS 0fi5po.5al *p!5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at '� �3 clr "t`,_ ; I It and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:ConstructiO must be completed within three years of the date of thi erm t Date: � U U _ Approved by G i TOWN OF BARNSTABLE LOC�ITION -S�0 Mazig L�+EM�: SEWAGE #e 0 - ®�f VII.LAGEArzn s 1 �� ASSESSOR'S MAP &LOT7fi-0y�-OoZ INSTALLER'S.NAME&PHONE SEPTIC TANK CAPACITY / Q Q j LEACHING FACII.TTY: (type) �00 C®-�en'r J)6cr�/l (size] L101 to Ia-� 10 h. NO.OF BEDROOMS A BUILDER OR OWNER PERMTTDATE: -•-4- COMPLIANCE DATE: 36 D 2 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 �20,6 a a .411 Town of Barnstable Department of Health,Safety,and Environmental Services Public Health Division Date J.61,Main Street,Hyannis MA 02601 IUaNBTABrl, ° 16 '�� Date Scheduled a Time 0 V(! w, Fee Pd.• �JV Soil Suitability AsSe,vsnient for Sewage Div sal Performed By: By: h✓r I ?>;:•?;:.::•: Owner's Name Location AddressCp G� J i I l+/^� 4tirnST°`ye Address ~ i S. O Assessor's Map/1'arcel: Z7 0 ¢�1'7— Engineer's Name Sf mow` /�/1 GL NEW CONSTRUCTION REPAIR Telephone!I ( Land Use Slopes(°/.) ' /S /y Siuface Stones Sam Distances from: Open Water Body NA ft Possible Wet Area N!a_R Drinking Water Well AAA ft ; i Alq ft Property Line ft Other ft Drainage Way P Y . SKETCH:(Strec(name,dlmenslons of lot,exact locations of Itsl holes do perc tests,locale wetlands in proximity to holes) • Z J o LET Z N j 7so w . 44> - i Parent material(geologic) Depth to bedrock Depth to Groundwater: Standing Water In Hole: Weeping from Ph race Estimated Seasonal High Groundwater ::...,..:......::........::...:.:..:........ W .............::.: Method Used: in. Depth to soil mottles: in. Depth Observed standing In obs.hole: in. Groundwater Adjustment ft• .Depth to weeping from side of obs.hole: Ad factor Adj.Groundwater Level .index Well N__ : •Rrading Data:_.--- Index Well level _^ (• '1)7 .......... Observation Time at 9" '37 Hole a Time at 6" Depth of Perc 0 Start Pre-soak Time // Time(9"-6") End Pre-soak Role Min./Inch Z&�s n-IAAI .AA10P1%i Site Suitability Assessment:, Site Passed V. Si1C Pelicd: Additional Testing Needed(YIN) .... .,.::::..::.;.:.. I: .::......... ... ::. T-3 on Soll Texture Soil Color .. Soft Other (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. t t P:.. . I3SEIt:Y..:�TT.t�N::�LpT:r :Lb:G:•.;::<<;;::•:,:.�:....::::... ...1:.:...:: ::f:::�:.::;<.::.;;.;:;:�:.:.:;>:<.>;::.. Depth from Soil Horiion Sol Tcxlure Soil Color Soil • Other Surface(in.) (USDA) (Munsell) . Willing (Structure,Stones,Boulderes. 41 /Z 34 Sao �o.y y ION Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA)' (Munscll) Mollling (Structure,Stones,Boulderes. p ....................... ::.:::::::::::::::::::.::.:>:: 1 :.; . .. :::::.:::..:.:.:::�r1ar.....o srr �.....:....::...rr: :..:x, :....:.::.::: :::.•:::::::. •..........::::•::::.;:;:.:.:•:.::. ...:.:.::...:.:..... .. . .. .:... .. Depth from 8011 Horizon $ofi Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (St(rtclure,Stones,Boulderes. ° ravel), rlood Incur ice Rate Mnn: Above 500 year flood boundary No Yes - tti a y r: t E _ 1. . r: 1 �. 1 — h pj 77777 1 � _ ----�->•:,,,.. ter-.. ,... ._._-- :..,. �.. �. ."�: ._. ... I. - .. .. ._ ..: ........ .-..... .. -_...- :.._. ., :. etc { L , e• . .. : , ,. ... -. .. "........ ... .. :.. ... ... �_.. .. ... ..:: 1.......:... -tom. ((-- , v: 1 # :5 GENERAL'NOTES THEGENERAL CONTRACTOR SHALL VERIFY ALL SITE CONDITIONS:AND.ALL DIMENSIONS AND .. '.NOTES ON ALL'DRAWINGS IN THIS SE7 PRIOR - ( I —_O ANY - SOART OF eNY WOR WORK REPANCIES PRIOR TO THE GENERAL CONTRACTOR SHALLINSURE THAT - .ALL WORK.CONFORMS:TO THE LATEST MASSACHUSETTS STATE BUILDING CODE(SIXTH EDITION)AND.AI-L OF THE LATEST LOCAL BUILDING CODE REQUIREMENTS. �ecou� t-'w-e2e t�-a.rv, dvF� s -77 7 77-77;* ---------- ---------- 7, z -77 .............. ------ 7 .......... ---------- .......... ,7 oil .......... ? 7777777