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0170 PALOMINO DRIVE - Health
a. .• '. _ f ... . ................ �I 1 Tyr L.1C� GA28AGt= C�Rt��1Z �.,a•tt_�( �L�w s 1t0 +� 3 � �3Ca G.p.D. ��.�5�-----•,._.._ _ 1 taf—riG 'T�1K = 33!?Y I�G % • 4-95 6.PU. dap 474'L. U,5i--- t00c.-� EA6.t..-. �t1o<,ru t=i-r - u sa=. t c�oc� �An>;._. W rTu r17&WAL-L MEn. = Ii -G.>✓. O`LZ` tp,S SF K "L o _ S-76`y�6.P.D. �. 44, MZeA '78 i;t - x a" _ &J, C'.RL?. i ToTp�. •t�A.i��( t=(1�W = 33p 6.PD. G'!✓f.ecDLLL1T10Q C�'l�T� Cmi 7j �t�tttrJ P'`"P } � R4 TA u ' • 49. , � E.C. s.. r? � �r (_st 2� lab T 5T I Tor T*No =i o 5 0 +�a.'TT nib It,ty--1-/,v �ooe I ooa tNw Lopx� 4~�a� DKT lu✓. Gal.. QG$ ` -Box �iG.f S rlc o 11JV. T1.1 r1 K 3 ' G,�t_. 9(, t cf( LAN FIT e STOW e- (,qo.o C—nZTtt=►i~L-D i P2,oT=-t L-E: e►�st! t.hGllTlot-1 P { 0 V'/d TWL , r' Pose-`t� I G tr tZ T t F-�( t-d A 7- T N G --D Vj a t_U t3!. 5"c p v►J Pt_A 1�1 1Z iv t= E�.i C_ W t"YP TO- Z: St.DtL t_t►�E= �jT , Td W rUA`T En �`{�1, _•et..� �/�t - (.�Y �c - t LA,"a 51 L)Zv a llf o t�S Tt-1l5 t7L_A►-1 I WOT 121A. C'L7 IJt'•-1 A" 0STEV-V1L-1-(;_ It,l�f"�'Jt✓�E�Wi ''�Ut'_�/t�� `Ct;C. c,Fc 5 <<, ,141AJw U`�G�? j"�� t7t`l t_t_M(t�11 t__o-C (-►1,1�-�� _`_`� _w_ ��. � - �I�(ols(�'t..Gl.•v� :.., ,Q.E� •�.:.:t... y�. it - No.. ..... ..... ... ....� ...... Fss :?. t-P THE COMMONWEALTH OF MASSACHUSETTS p BOARD OE- HEALTH I ......................... , p liratiianJlar i o tt1 ork C omatrurtiun amit Application is hereby made for a Permit to Construct ( or Repair '( , ) an Individual Sewage Disposal System at: _ Location-Address or Lot No Own e Address a ................................ Q Installer '. Address Type Of Building. , Size Lot-------------------- ------Sq. feet Dwelling—No. of Bedrooms..........3.............................Expansion Attic WI-) Garbage Grinder (No) Other—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -----------=-----------------------•--- . Design Flow_____ .._..... gallons per person per day. Total daily flow.__._ W g _ g P P P Y Y gallons. WSeptic Tank—Liquid capacity i Ogallons Length___ ' '` Width.. _ : Diameter................ Depth.. x Disposal Trench—No.---------•-_--____-• Width............... ... Total Length.................... Total leaching area*___. -_,-----sq. ft. Seepage Pit No......... ........... Diameter___... :___.___ Depth belowAnlet_ `_: Total leaching area.. ___. _.__sq. ft. z Other Distribution box ( ) Dosing:taUk Percolation Test Results Performed by _ ._, Date.... j_ a � '"*--- �-- - -�,�=------,�•• 1 �---------- fit/c-!f •- i Test Pit No. 1................minutes per inch Depth of Test Pit___:__ ..... Depth to ground water... Test Pit No. 2................minutes per inch Depth of Test Pit:...........:._..... Depth to ground water........................ f I . . O Description of Soil=--=C ."` 1 ' i . i': E. t41 C i. - ________________________________________________________________ ___________ ______________________________________________`..._.___...._._.._........__ __._ _ _-__-__•-_ V _____ __ _ W .............................................................................................................................................................................................----------- UNature of Repairs or Alterations—Answer when applicable-------------------------------------- w_..._____.._....._...__.._.:._ :................. ........................................................ =------------•----•---••••--••---•--------•-------------- Agreement: ' # The,undersigned agrees to install the`aforedescribed Individual Sewage Disposal System in accordance,with .the provisions of TITLs 5 of the State Sanitary Code—The undersigned further agrees not tolpface the system in £ , operation until a'Certificate of Compliance has be@i3 sued by the board of-health Sig ... ---- r '� Application Approved BY • Application Disapproved for the f ollowing`reasons:. r � a ate ______________________________________________________y.._'____._.___.__._______._..........______'___...__..____...___..______._.. ........__._________._.._.__.__ .. ......................... y, Date PermitNo........................................................... Issued-...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF HEALTH Q ... ,�....OF..... ,�,g% ........................... ........ ...... t .,:.... �prtifirtttp f (�u�t��itt�trr THIS IS TO ERTIFY, That the Individual Sewage Disposal System constructed ( ).or Repaired ( ) by---------------- --------------........-•••--_. --••--------••-----•••••-•--......••....._. �- y ! ./f Installer P �^/�s I �I At has been installed in accordance wit11 the provisions of 5 of The State Sanitary Code as described n the application for bisposal Works Construction Permit tiro. _ P dated _`._ THE ISSUANCE, OF.-THIS CERTIFICATE"SHALL.NOT BE-.CONSTRUED ' AA GUARANTEE :..T._.". T_THE, SYSTEM WILL FUNCTION SATISFACTORY.' .... -- sptor::.DATE...:::......�.... S --------- THE - COMMONWEALTH OF MASSACHUSETTS `t. BOARD OF HEALTH . ............0 F............ .. No.._••__•• .�../.� ... FEE........................ ;s Permissio is hereby granted----------------------------------------------..--...-•---•......-- . -----------------------..........--- to Construct ( or Repair j t) an Individual Sewage Disposal System atNo. ...............................................-.......................................................................................... '`as shown on the application for Disposal Works Construction Per i Street o.._____. �S�d 7 •-----•--- -------------- ........... - ------ ...__••... Board of e DATE.... = / . Boa altli FORM 1255 HOBBS & WARREN, INC., PUBLISHERS :i CIA fA. t aGj THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��/C�✓✓�' c. ............of.. .f . i '........................ Appliratiou for Biipniia1 Workp Tnnitrurtion. rantit Application is hereby made for a Permit to Construct (4r Repair ( ) an Individual Sewage Disposal System at: ma�: .. .... :. s �'... ..................... �� ... ................... __ r ss ( � .:- gor Lot No. . �i_L`_Lation �e_+�' /.P.--•----•_•..A_:.®. caner Address a •--••--•--------...�_�?kt•�-..... -.4 1......-•----•..............•-•. ----••-•-•--_-_-•--�' '�7�.11.�..�.I&-------•--..._...---........_._. Installer Address d Type of Building Size Lot.............................Sq. feet U Dwelling—No. of Bedrooms.___.__._�____________________________Expansion Attic (p�) Garbage Grinder,(P!Q) '4 Other—Type e of Building No. of ersons____________________________ Showers — Cafeteria a YP g P ( ) ( ) P4 Other fixtures ...................................................... W Design Flow............... _______________________gallons per person per day. Total daily flow.......... 5_0......................gallons. WSeptic Tank—Liquid capacity_I b .gallons ,Length____46.4,a Width._..Y_=M'Diameter________________ Depth___*/* iC. x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area-- - _�_ ...sq. ft. Seepage Pit No----------�_-------- Diameter.......J.�-...... Depth below,'nletr.�___.fA .....__ Total leaching area___ q. ft. z Other Distribution box ( ) Dosing to k ( 0 /" 1-3- 7. Percolation Test Results Performed by--- . _...... _ '------------ Date__________________________ ._. Test Pit No. 1_.,3--------minutes per inch Depth of Test Pit_____ ___ _________ Depth to ground water_.____ .......... G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ...........-•.....................................................................t.......................................................................... Description of Soil �? .. 1"q�!4 _ _ .l�l_ ..............................................�.••�?Al ---.. 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 TIT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be ssued by the board of health. c� Sig d._:_ 1% ...._... Date Application Approved BY ------0_.. ... • --'��. . ••-••-••__--•-•- -••- ......l�S_--_7•y, �_� Date Application Disapproved for the following reasons----------------------------•-----------------------------------------------•----------------------------••---- ................•--•-•----•••-----•--•._......-----••---•••----•-•------------------•.......---•--.....--••--••--....-----•-----••••-----------•---•--•-•--•-------•--------------------------•........_ Date PermitNo........................................................ Issued....................................................... Date TOWN OF BARNSTABLE LOr.`,LTION ?0 f 4�®+`�►.+a Dr - SEWAGE # VILLAGE ?a✓n 5h LQ— ASSESSOR'S MAP& LOTg 2K 0"13 -En. p,-4Or S NAME&PHONE NO. �r�a� K•T. /tivn 50$-25s'-p3y3 SEPTIC TANK CAPACITY Do o r A t_ LEACHING FACILITY: (type) / Gxb pi¢ w41 r s6iD'4-(size) 2002 5-4L NO.OF BEDROOMS 3 BUILDER OR OWNER M1 cAld PERMUDATE: COMPLIANCE DATE: Separation Distance.Between the: (F-ro.q 5o No wRTElz £*cou^-k.,ed(1V) Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ NIA Feet Edge of Wetland and Leaching Facility(If any wetlands exist H/A within 300 feet of leaching facility) �" ! Feet - Furnished by �t j rt K T� + / ,e Aui/c);.ft M44 l& W 4 C.tZe Cod r e' B ; R I - 13' 1{ 3 too 3 3: 39� 3 0 N oT To SCALE -r2- LOCATION l �" S;E.WAGE PERMIT VILLAGE INSTA LLER'S NAMIE i ADDRESS ,? 9-- S 2.00 B U I L D E R OR OWNER' DA T E PERMIT ISSUED 4 �' lu.��9 e — DAT E COMPLIANCE ISSUED (,&A 1 I IZ) Y a.; f Commonwealth of Massachusetts Title 5 Official Inspection Form P�7�'�3�P �3 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` !70 A4Lo n 1,41b DAI VF Property Address Owner Owner's Name information is required for every 1� 'r` Z) �z page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information on the computer, I use only the tab 1. Inspector: key to move your cursor-do not C—P use the return Inspector Name of I key. C11 S- 6-00z* Y'-z-&Z Company Name �U 13ox 177-9 Company Address AW a1Jle& ilil,�F oZs�3 Cityrrown State Zip Code 09- <568 34-t q Telephone Num Ucense 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: --i Passes fZEE P( ❑ Conditionally Passes ❑ Fails-., ❑ Needs Further Evaluation by the Local Approving Authority ' ecto s nature DateIn t The system inspector shall submit a copy of this inspection report to the Approving Authority(Board rs1 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. Mns•11/10 Title 5 Offidal Inspocflon Form:Subsurface Sewage Disposal System•Pape 1 of 17 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l ZD A4CoAft vc> Property Address Owner Owners Name information is required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: r I ark B) stem Conditionally Passes: . ❑ On r more system components as described in the"Conditional Pass"section need to be replace or repaired.The system, upon completion of the replacement or repair,as approved by the Board Health,will pass. Check the box for"y " "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please exp ' The septic tank is metal and o 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infilt 'on or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replac with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is s turally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y rs old is available. ❑ Y ❑ N ❑ ND(Explain below): I i I t5ins•11/10 Title 5 Olfidal Irapedlon Form.Subsurface Sewage Disposal SY81em•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Ww"lac-z Owner Owners Name Information is &MIS7216«- O��o Z l6-�/ required for every page. aty/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Obse tion of sewage backup or break out or high static water level in the distribution box due to broken obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspecti if(with approval of Board of Health): ❑ broken pipe are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is rem d ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is levele replaced ❑ Y ❑ N ❑ ND(Explain below): I ❑ The system required pumping more than 4 times a year due to b ken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health). ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND( lain below): 111A C) her Evaluation is Required by the Board of Health: ❑ Conditions e ich require further evaluation by the Board of Health in order to determine if the system is failing otect public health,safety or the environment. 1. System will pass unless of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not oning 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 It marsh t5ins-11110 Title 5 OlBdal Inapedlon Form Submalaos Smpe Disposal System-Pa of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) W/ 2. stem will fail unless the Board of Health(and Public Water Supplier,if any) date 'nes that the system Is functioning in a manner that protects the public health, safety a environment: ❑ The sy m has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surfs ter supply or tributary to a surface water supply: ❑ The system has ptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic k and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS 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 DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammoni itrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are tri ered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indite"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage til te-,facility or system component due to overloaded or clogged SAS or cesspal' ❑ Discharge or ponding of effluen►ra-tbe surface of the ground or surface waters due to an overloaded or clogged SAS 6eCs"nool Static liquid level in the distribution box above iage,t invert due to an overloaded ❑ or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available vollume is less NrA than' day flow F t5ins•11110 Title 5 Official Inspection Fore Subsurfece Sewape Disposal System•Pape 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Property Address Owner Owners Name information is ��. required for every _ 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: ❑ 14 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. ❑A11 EA Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑~/4 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.) ❑ N/ ® The system is a cesspool serving a facility with a design flow of 2000gpd- �F 10,000gpd. ❑ [P 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. N14 Ey,.jLar9e Systems: To be considered a large system the system must serve a' facility with a n flow of 10,000 gpd to 15,000 gpd. For large s ms, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Se D. Yes No ❑ ❑ the system is n 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 t of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nit r n sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone f a public water supply well If you have answered'yes"to any question in Section E the s ern is considered a significant threat, or answered"yes"in Section D above the large system has faile . e owner or operator of any large system considered a significant threat under Section E or failed unde ction D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should act the appropriate regional office of the Department. t5ins•11110 Title 5 Of idal Inspection Form:Subsurface Sewage Di I System•Page 5 of V f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a` l Z0��o�rjfro Property Address i�/�e2• Owner Owners Name information is AO^/s0W, 06C6 required for every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: 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,exelvdiR@ the SAS, located on site? {�lt:�.uDlnl` ❑ 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): `� Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 t5ins•11110 Title 5 Official I nspecdon Form:Subsurface Sewage Disposal System•Pepe 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` /7t, AwCo.r No Property Address �grt/OEL Owner Owner's Name information is d required for every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: �D0 e ol<' /dva /.Ac Z Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 9 No Laundry system inspected? ❑ Yes IN No Seasonaluse? ❑ Yes Qjr No Water meter readings,if available(last 2 years usage(gpd)): 2�9 Zoo Detail: Sump pump? ❑ Yes [K No cUl? Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Estab is Design flow(based on 310 C .203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc. . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes No Water meter readings,if available: t5ins•11/10 Title 5 Offidal Inspedfon Form Subsurfew Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name information is required for every , g¢.✓,Sjap,QU '� �1G30 Z-��'��� page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date o /use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? W Yes No 1/ If yes,volume pumped: gall��How was quantity pumped determined? Reason for pumping: d dy e9enT Type of System: XSeptic tank,��, 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-11110 Title 5 Official Inspeotlon Form:Subsurface Sewage Disposal System•Pape 8 of 17 Commonwealth of Massachusetts Is 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name `. information is �R+RN,S'T.��3C.F /ILL— Q�►,�D 2- /6/� required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 79 /� �/ a Vows Were sewage odors detected when arriving at the site? ❑ Yes 191 No Building Sewer(locate on site plan): Z Depth below grade: feet Material of construction: ❑cast iron 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet � E feet Comments(ongnditiy9��of joints,venting,evidence of leakage,etc.): 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:4/11 f- years��� Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes Rj No/V14 Dimensions: -0e AQ�X 6 r G`t K sL$I` Z�• Sludge depth: t5ins•11/10 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts _ p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is .- required for every f���✓`f��}B4� �a� page. City/Town Stat Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) e` Distance from top of sludge to bottom of outlet tee or baffle 2 4 `r Scum thickness Distance from top of scum to top of outlet tee or baffle Z �r Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? eff Comments(on pumping recommendations Inlet and outle tee or baffle conditio ural integri , Cliquid I�srelated;o outlet invert, �\c�e of leakage, etc.): Ole a 44 ke L-en4czl 401 -PSr1e-d7;e vd .,Y/JeV s a/ ov7�lPf d ccesr Grease Trap(locate on site plan):,p� Depth belo rade: feet Material of construc ❑concrete ❑ meta ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date. t5ins•11/10 Title 5 Ofiidal Inspection Form SubWace Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is i3f i✓91,44 4'1G.3J Z-/y-!l required for every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) N/ C mments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liqui s 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 be grade: Material of cons lion. ❑concrete ❑ m I El fiberglass [I polyethylene ❑ other(explain): Dimensions: Capacity: lions Design Flow: gallons day Alarm present: ❑ Yes No Alarm level: Alarm in working o ❑ 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•11110 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form a Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 'e / -D ,Pez0"/,P/d Property Address 44 Owner Owner's Name information is required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 1,1 Distribution Box(if present must be opened) (locate on site plan) 't Depth of id level above outlet invert Comments(note' ox is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage i or out of box, etc.): /V� P p Chamber(locate on site plan): Pumps in wo • order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamb ndition of pumps and appurtenances,etc.): Soil Absorption System (SAS) (locate on site plan,excavation not required): .0 SAS 40 located, explain why: �f / /0:srso xv I— //' �Q/- c t5lns•11110 Title 5 Ofifdel Inspedon Form:SubsuAace Sewage DI p sposal system•page 12 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rt • �D I,�f Property Address Owner Owners Name information is required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: NA dxAF W leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments(note tion f soil,signs�of hydr lic f ilure,lev I of ponding,da p foil, ondPion of vegetatio ,etc.): C� YlvVirl G KG �d 4e xi$4 VIA — LY-e // i •t �--_ G(/ Z �5 7`iAc,P iV1074 93 �✓ e�r ►i a�,z e 4W Yi'a A Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Numbe d configuration Depth—top of liquid o vert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5lns•11/10 Title 5 Mild Inspection Form:Subsurface Sewage Disposal System•Pape 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments Property Address Owner Owner's Name information isai����� required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) y4,-Cho me note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materia f construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydra ilure, level of ponding,condition of vegetation, etc.): t5ins-11110 Title 5 OfBdal Inspection Form:Subsurface Sewage Disposal System•Pepe 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rY /-7,9/-24WAOV4 Property Address �� i�f�7rv®�L Owner Owner's Name information is sw- /Wm_ OZG30 Z-lG-// required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 --Cs =o '' • L © fNL t5ins•1 to o Tine 5 Of6aal Inspeaon Fom subsurface Sew a Disposei System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every �"����.•77 � !�� page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 0 Check Slope 0/0 Surface waterA114 Check cellar 41r Shallow wells N�� � 1�✓y�.C�/, }%/� yrh'io Estimated depth to high group water: feet 2 Please indicate all methods used to determine the high ground water elevation: 4:�4s [� Obtained from system design plans on record If checked, date of design plan reviewed: Da2 7 d� S Sv/Z✓�/ r 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: S ,Say /2--'�f •v� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /7D Property Address/� Owner Owner's Name information is required for every page, Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file M Mina•11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Dis posal aposel System•Pape 17 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form i Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 2?00'/ Important: / When filling out 1. Property Information: forms on the � � computer, use 170 Palomino Dr. Barnstable, Ma. only the tab key Property Address to move your Michael Mitchell cursor-do not use the return Owner's Name ; key. 170 Palomino dr. Owner's Address r� Barnstable Ma. 02630-1502 City/Town State Zip Code Date of Inspection: 11/22/2006Date 2. Inspector: Brian K. Tilton Name of Inspector The Building Inspector of Cape Cod Company Name P.O. Box 307 Company Address Eastham Ma. 62642 City/Town State Zip Code;—:a 14 508-255-9343 # `- _ Telephone Number h3 C7 B. Certification I certify that I have personally inspected the sewage disposal system at this addre s and fit theme information reported below is true, accurate and complete as of the time of the inspectioncThe iri-pection was performed based on my training and experience in the proper function and m intenanCb of bar site sewage disposal systems. I am a DEP approved system inspector pursuant t Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑gNeds Further Evaluati by�theLoc�alApp�roving Authority 11/27/2006 In pector'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. 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• ` Page 1 of 16 • Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection 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: All components in place and functioning normally. 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: 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 170 Palomino Dr. { Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date.of Inspection 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 ❑ 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: 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 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3 of 16 r� Commonwealth of Massachusetts Title 5 Official Inspection` Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and'SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method"used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified/laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. 170.palomino t5insp.doc•03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M B. Certification (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State ZipCode Michael Mitchell 11/22/2006 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 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. 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form B. Certification (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is.considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Foram Not for Voluntary Assessments Subsurface Sewage Disposal System Form 1M C. Checklist 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection 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.ins,pected'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? 1 ® ❑ 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)] • 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form G1M - D. System Information 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 376 Number of current residents: 1 Does residence have a garbage.grinder? ❑ Yes ® No Is laundry-on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d '05=200GPD/'04 9 ( Y g (gpd)): =219GPD Sump pump? ❑ Yes ® No Last date of occupancy: Current. Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town . State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Tenant Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract.(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 3/5/1979 Were w r sewage odors detected when arriving at the site? El Yes ® No 170 palomino t5insp.doc-03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iV M Subsurface Sewage Disposal System Form D. System Information (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection Building Sewer (locate on site plan): Depth below grade: 5 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.): Septic Tank (locate on site plan): Depth below grade: 4,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 El Yes ❑ No certificate) -------------------------------------------------------------------------------------------------------------------------- • Dimensions: 5'8"x9'6."x4'10" Sludge depth: 8 Distance from top of sludge to bottom of outlet tee or baffle 22" , Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Dip stick, Baffle stick &Tape measure. 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M D. System Information (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell , 11/22/2006 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Levels normal , Baffles intact , no evidence of leaks or back up into tank or d-box. System should be pumped for regular maintenance. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, 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: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 r I Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4�M D. System Information (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: N/A 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of.leakage into or out of box, etc.): D-box level no evidence of leaks or solids carryover. One outlet to single pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and'appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: z leaching pits number: 1 ❑ . leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ' Lawn over top with riser to within 12" of surface6x6 pit with 2' stone, pit excavated to reveal 1 foot of ponding in bottom. no evidence of hydraulic failure or breakout. Bottom of SAS 12' below surface. 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13.of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form lo Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form D. System Information (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection 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 Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privylocate on site plan): ( p ) Materials of construction: N/A Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form o Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cunt.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 Cityfrown State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection 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. N OT- T-o 43(A LE' A 3 v� fl 32 �oJ� 2 350 / ��°� 2 Q a Z 30� N (von V 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection. Fora Not for Voluntary Assessments Subsurface Sewage.Disposal System Form D. System Information (cont.) 170 Palomino Dr. Property Address Barnstable Ma. 02630-1502 City/Town State Zip Code Michael Mitchell 11/22/2006 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: f. J2 r S Ad1ag.�td Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 3/5/1979 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: Corrected to estimated high water table using Frimpter method. You must describe how you established the high ground water elevation: Hand auger 4" test hole within 50' of SAS to a depth of 15', no water encountered. Estimated > 12.8' below surface. 170 palomino t5insp.doc•03/2006 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) m A-- ' =-= -1 F-N L DATA {r'r y, �y }�y�.µ�'y�r���Y p .� � ,r�c- H�� Y4�3 �QTj]��.CL+ ,•: _ 1— / � �7�'''�','�, 3 4,,06 lf.. ^'���\.v i. �� ��'�Y��ety+v;,ti'�•t' ^Sr' � ^C��• .". Z • 1 i e"q' y* ��•;. Siy S `.Er. _�3. Gi f, � Yt? .�"� •'j.�2+l.:.t r•S -S : 4 [ju .,,��.� KAI ' "fit" ' ♦♦Y�" � Y �" `„".y y � ,r �. a 1r.-hj.�. d°,� y�r '> ys.•i�l.' m3 _� C - � S,v: i f .S, .,.s .- � .y^.. ,tic'•` ->y� 7�y��� � yq`�r` �.::• r y I' �.v p� wti8-:�+irr -.yu,. ry�.•hF r a���Y� lt'•4 3 t K t � 1 +1', � '":.ti "L �Y AI �., .- ` .� f�.�i{.�!} +i- _� G .i�AO- y y.,. = i � •' i FtT 1 t i"C.' a 7 p rev .1,. i --yr ..'s�Y - r��. - � ��•r,. ,_.r � _ { � �-`�� µme'..-. ZL r � � M � "'u°*.•'+. _-•e�s L ."i-••Y 3- i Yt t '�TaZ��,u,F: !�,��A^�JiC S.,�%-J r•iP"' �- -.lop � �-,�,., .._..�a -il'fi�' � •x- ,r..�. :,�d�A1'�+;....". mow:..��+rc:•�.r++�.�..._.. � ... 4* i .^ �Y.� _ s� �.-..3r tug+^.' •r t^ A r 't �.+` i.--.^ � ..F- e.?w•�ii•f-4ti;1c is �, �j ,.} •. fJ— - ?A _ wY/' b:tr-� "� 'sir L �-t i"•y f�. � t � ; t ,� ,.j �'•n <a•es.:.c,�a z'a-+sr�>•:t\SYs+4 4 -r � -,•� ay. �� • �'�_ 4 '�f! •1C k �Y Ts - 1 a f y .yam' i �i `fir• >� � u •.)� y M• r •,r.:fF 4{r �s.. \: v� r `kT, .- *�, r..` i '.1 .^ Iyfi•_ �.,*-4 ft-� 1 r' • l'C�9 Permit-Number: Date: Completed by.: rian K• 77/col HiGI-1 GROUND-WATER LEVEL COMPUTATION Site Location: Lot MO. Ovvner: ��� M i{ C�tf Acinress: r70 /___r�° (�a•.inra l�Y �1�aG4" �p,� a �. ljoX 3v9 Cat s��a /'t4 . f Contractor: 74 $yi���iu `— �'�/ `�oe� Aduress: a• -F 2 (Votes: 11(n r;Ja' �'•�CovK¢�ei�ed /(o STEP 1 Measure depth to water table lllzz/ob /(,% tonearest 1 J10 ft. .............................................................................. .Da}e _ monxh(day(year _--- STEP 2 Using WatecAevel Range Gone _.__ _._•. _.____:_. .._. and Index Well Map locate ? site and determine: �A Appropriate index well................................................... ? � 8 UVater-level range zone•..............................-••--••.-•••-•---••-�� ` o STEP 3 Using monthly report"Current Water Resources Conditions- determine current dep h tip t' la o6 23./ water level for index well---------- --------------- 1 i j rnflntfiiyear i i ' , STEP n. Using Table of Water-level Adjustments foi index well (STEP 2A), current depth j to water level for index well (STEP 3), and water-!e;�al zone (STEP 2B) determine water-level adiustrr:an_ -----__•_•-_............................................................ i STEP b Estimate depth to lilgh vviatei by subtracting the:water- level adjustrrent(STEP 4) + from measured depth to uvater level at site ;STEP 1.) ........................... g Figure 13,--Reprodueible computation form. i Cape Cod Commission: USGS Well Data-October 2006 Page 1 of 2 United States'Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties,the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month.They are published as soon as possible thereafter. - Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience, we've also provided links to USGS national and state data. See the hist column in the table and the footnotes below. To see what's happening in real time at a separate well in Brewster,visit the USGS site: IJSGS. 414630070014901_MA-BMW 22 BREWSTER,_MA -A record high was broken in June 2006 For further information about any of the data or links on this page,please contact Hydrologist Gabrielle. Belfit at the Commission offices(508-362-3828). October 2006 t!SGS Site Water Record Record Departure from Number**** Location Well No. Level* High* Low* Average* (.links to USGS Monthly Overall national water-level 11 database) Barnstable 234 23.8 2Q.5 26.6 0.7 -0.2 41395607016430.1_ Barnstable 24W 23.1 20.5 28.6 2.0 1.4 [E45407.0.16.500J. Brewster BMW 21 8.4 6.9 13.6 2 0 1.7 41.45180700203011 Chatham CGW 138 24.2 2Q.9 26.6 0.4 -0.3 41_4 1.00070011.1.01_ Mashpee MIW 29 8.7 5.6 10.0 0.5 -0.2 41.35250702919E)4 Sandwich ZDZ 47.3 45.8 . 48.2 0.3 0.0 41.441.8.07024160_1 Sandwich ZDw 48.1 45.8 55.I 2.3 2.0 4141.2-4070?65901. Truro TSW 89 12.1 10.2 13.0 0.3 -0.1 42020607Q0459U1. I Oil Sp Ow iorwn Fi 1� iTv ' MPA iiiie -•n1i Ylg� " �y .��l. - � �•!r? ��•Y.�` TT!`�»� �.f•,��-��r f.. �tYa�.�`,+�w. �i >y;S �` 0-- n ►r#` i�t�sttlj� `1^: CAM ♦ {�"^'ar 1 �� M rr I [y��Res P• ,w + - .s. A. i/ •+'fir ..�. ���+4„��r s_ 'C. � fee 71 ow �/b- . •i f - T Win 05 ,�,��'�, � •.�f 1�'_ ..moo t ��r ,}Y y�• +:r.� xs , s a �• 11 , e