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Home My WebLink About0009 SALT ROCK ROAD - Health f 9 SALT ROCK RD. BARNSTABLE A = 298 038 r r ' �7 L ° CI a �I d o 0 r I 4' 6i, t f f f '� I.F �: r Health Master Detail Page 1 of 1 � A 6A. t :nHeal as er Logged In As: TOWN\health Health Master Detail Thursday, April 24 2014 Application Center Parcel Lookup Selection Items 1 Parcel Septic Perc Well Fuel Tank I 298-038 Location: 9 SALT ROCK ROAD, BARNSTABLE Owner: DOUGHERTY, HUBERT/MADELEINE TR Business name: vI Business phone:�� Rental property: f Deed restricted: r Number of bedrooms : 31 Contaminant released: r Fuel storage tank permit: r Save Parcel Changes � � � Return�to Lookup Parcel Info Parcel ID: 298-038 Developer lot:LOT 11 Location:9 SALT ROCK ROAD Primary frontage: 193 Secondary road:BRAGG'S LANE Secondary frontage: 127 village:BARNSTABLE Fire district:BARNSTABLE Town sewer exists at this address:No Road index: 1412 My Interactive map. AP (Aquifer Protection Overlay Town zone of contribution: State zone of contribution:OUT District) Owner Info Owner: DOUGHERTY, HUBERT/MADELEINE Co-owner:NINE SALT ROCK RD NOM TR TRUST Streetl:9 SALT ROCK RD Street2: City:BARNSTABLE State:MA Zip: 02630 Country: Deed date: 12/1/1999 Deed_ reference: 12696/187 Land Info Acres: 0.58 Use: Single Fam MDL-01 Zoning:RF-2 Neighborhood: 0105 Topography:Above Street Road:Paved Utilities:Septic,Gas,Public Water Location: Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bathrooms 1 1974 836 2416 3 Bedroom 3 Full Buildings value:$178,700.00 Extra features: $56,400.00 Land value: $114,900.00 htt ://iss 12/intranet/healthMaster/HealthMasterDetail.as x?ID=298038 4/24/2014 r � r �� r► � ��Irk��s n � �, ? � � y� s k x a -[ V►iYlk } ..................... ............................... .................... ................ ..........-- .................... .......... -RAI, 1 7,-) Z22 E C>l TOWN OFBARNSTABLE LOCATION S41-� Rock R, 11 SEWAGE# NgLLAGE ( AmS4-464 ASSESSOR'S MAP MAP & LOT ar INSTALLER'S NAME&PHONE NO. S S ST SEPTIC TANK CAPACITY �V LEACHING FACILITY: ( PC) ►T (size) &X(0 NO.OF BEDROOMS BUILDER OR OWNER ✓ Ar reT" PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r i At, as 3I - ! ` , ('" I AA aa' ° . A3 a a, 133 3 A y 3� y TOWN OF BARNSTABLE LOCATION q ��j accK- SEWAGE # -7 V-.F VILLAGE PJS-Ci r(iic ASSESSOR'S MAP 6 LOT NSTALLER'S NAME & PHONE NO. C.c.is ` /ZO5. CvA`S t �!L•�'� 37 S PTIC TANK CAPACITY d EACHING FACILITY:(Cype) T L( CAP jiaFi `-rziti�(size) . 9 37iXa,F.i�oI NO. OF BEDROOMS-\PRIVATE WELL OR PUBLIC WATER (`i5i►i� BUILDER OR OWNER DATE PERMIT ISSUED: ' DATE COMPLIANCE ISSUED: J VARIANCE GRANTED: Yes No i p rJ V , t r TOWN OF BARNSTABLE VOCATION SA LI IROGt� �.� SEWAGE # VILLAGE aA(A3�4UJL ASSESSOR'S MAP& LOT 97 03$= INSTALLER'S NAME&PHONE NO. l SEPTIC TANK CAPAC= S ► S S► w� LEACHING FACIL=: (type) �` �► cy 2Ss ad 1 (size) NO.OF BEDROOMS BUILDER OR OWNER r (Cr UAL 6 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .� CiD _._. cif � o W f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, /) use only the tab 1. Inspector: (uU( key to move your I cursor-do not Michael DiBuono use the return Name of Inspector key. NEIGHBORHOOD WASTE WATER SERVICES raa Company Name 350 MAIN STREET Company Address W. YARMOUTH MA 02673 City/Town State Zip Code 508-775-2820 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 04/09/2014 spector'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 Inspecti Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or'E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use.according to the home owner. The.other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 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): There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system.consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1: System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts N r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 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: There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or El clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume iswless than '/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 Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 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. ❑ N Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you-must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): _ 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r N Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Salt Rock rd Property Address h D hert Hug ou y Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?,(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑, Yes ❑ No Water meter readings, if available last 2 ears usage d 2012 58,000 g ( y g (gp ))' 2013 58,000 Detail: 158.33 GPD usage over the last two years. Sump pump? ❑ Yes ® No Last date of'occu anc : occupied p y 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 �^M 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: occupied . Date Other(describe below): There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. General Information Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 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: The main system was installed in 1999 Off the back of the house. That system has the 1500 gallon tank. The age of the second system is not documented. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 32" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. Septic Tank(locate on site plan): Depth below grade: 26"system#1 24".system#2 p g feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. If tank is metal, list age: years ' Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑. Yes ❑ No Dimensions: #1 1500 Gallon#2 1000 Gallon Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts. W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 9 Salt Rock rd M Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. Cityfrown 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 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 22" . 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.):, There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle { Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts fo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �qM 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is Barnstable MA 02630 04/09/2014 required for every _ 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 Level and working properly 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.): There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. 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.): There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits _ number: 2 ❑ 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.): There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): : Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. Cityrrown 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.): There are two systems on this property. Both systems are in good working order. One system is a thousand gallon septic tank a Distribution box and a concrete leach pit.that is dry and does not get much use according to the home owner. The other system consists of a 1500 gallon septic tank a Distribution box and five high cap leaching chambers. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of pon ding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 J TOWN OF BARNSTABLE LOCATION IG41g,,-cr, SEWAGE # 7 1/9 VILLAGE ASSESSOR'S MAP & LOT � NSTALLER'S NAME & PHONE NO. S/Z05, Cv-jS 1 3icp - a 3 7 S PTIC TANK CAPACITY - EACHING FACILITY:(gpe)_,,:�j 4 9�X 37-X irtzO NO. OF BEDROOMS S�yPRIVATE WELL OR PUBLIC WATER t0Uf5ij� r . BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUELI :..�_ .,.�_...,_( wAl VARIANCE GRANTED: Yes No .a oil G' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) A Property Address: 9 Salt Rock Road, Barnstable, MA ' Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 Map: 298 Parcel: 038 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Qz CArA&f 3 _ a A3 o f 1 _ , revised 9/2/98 Page 10of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Salt Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: 1 -6'x 6' leaching chambers, number- leaching galleries, number: leaching trenches, number, length: leaching fields,number, dimensions.- overflow cesspool, number: Alternative system: Name of Technology: Comments:. (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) The pit was dry. The bottom to grade was 16'6". CESSPOOLS: None (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . revised 9/2/98 Page 9oflt Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forni Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Salt Rock rd Property Address Hugh Douherty Owner Owner's Name information is Barnstable MA 02630 04/09/2014 .required for every page. Cityrrown State Zip Code. Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: , 47 +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: pate ❑ 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: According to the lat inspection report by inspector James Ford ground water is at 47+ ft. Information was provided by USGS Maps and board of health Before.filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 o^ 9 Salt Rock rd M Property Address Hugh Douherty Owner Owner's Name information is required for every Barnstable MA 02630 04/09/2014 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 • — COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION SEPTIC SYSTEM#2 y Property Address: 9 Salt Rock Road, Barnstable, MA Name of Owner: Margaret J:Huntley Address of Owner: Same Date of Inspection: July 22, 1999 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville MA 02655-0049 Telephone Number: (508)862-9400 Map: 298 CERTIFICATION STATEMENT Parcel: 038 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs FurqEval By the Local Approving Authority Fails Inspector's Signature: NWT Date: July 27, 1999 The System Inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS , 01 �� revised 9/2/98 Page I of II F Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Salt Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 INSPECTION SUMMARY: Check A, B, C, or D A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. LIf"not determined", explain why not. The septic tank is metal,.unless the owner or operator has provided the system inspector with a copy of a Certificate of- Compliance(attached)indicating that.the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) y Property Address: 9 Salt Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well: The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm- Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Salt Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 D. SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due,to an 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional' office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 Salt Rock Road, Barnstable,AM Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 Check if the following have been done: You must indicate either"Yes" or "No" as to each of the following: Yes No ✓ _ Pumping information was provided by the owner, occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components,excluding the Soil Absorption System, have been located on the site. ✓ — The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ Existing information. For example, Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)l• ✓ _ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of + SubSurface Disposal Systems. revised 9/2/98 Pag e 5 of 1 I , I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 Salt Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 RESIDENTIAL: FLOW CONDITIONS ` Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 4 House has 2 septic systems Total DESIGN flow n/a Number of current residents: I Garbage grinder(yes or no): No Laundry(separate system) (yes or no): No ; If yes, separate inspection required Laundry system inspected(yes or no): No laundry on this system Seasonal use(yes or no): No Water meter readings, if available(last two yeargs usage(gpd): 1998-65,000 gals.; 1997-58 000 gals (total house usage) Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gvd(Based on 15.203) Basis of design flow ` Grease trap present: (yes or no) _ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Never pumped-per owner. System pumped as part of inspection(yes or no): No ` If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: 1982-per as built card. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION (continued) Property Address: 9 Salt Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8'6" x 4'10" x 5' (1000 gal.) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 10" . How dimensions were determined: Measuring stick Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) The inlet tee and outlet baffle were present.. The liquid level was even with the outlet invert. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete metal _Fiberglass Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recormendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) ' revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Salt Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time, of inspection) " (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present: Alarm level: Alarm in working order: Yes No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: Even Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.) The box was level and there were no signs of solids PUMP CHAMBER: None , (locate on site plan) r Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8oftl t r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Salt Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: I -6'x 6' leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.) The pit was dry. The bottom to grade was 16'6" CESSPOOLS: None (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIVY: None (locate on site plan) - Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of 11 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Sall Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 Map: 298 Parcel: 038 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) O OC , GArA&?- A a�,, a Aa as rc� 33_ Ay revised 9/2/98 Page 10of I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Salt Rock Road, Barnstable, MA Owner: Margaret J. Huntley Date of Inspection: July 22, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 47+/- Feet r Please indicate all the methods used.to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators, installers ✓ Used USGS Data ' Describe how you established the High Groundwater Elevation. Must be completed) Using the Barnstable topographic and water contours maps, the maps were showing approximately 47' +/- to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or,guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page I of I No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Mi-opool bpgtem Construction i3ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel 11. o. AVII Assessor's Map/Parcel 7_9F, O-S S"/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,�5t4.r 40 i✓.r' (moo Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(AW Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow er gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /�`a Lev .o d Type of S.A.S. � Description of Soil Nature of Repairs or Alterations(Answer when applicable) ��+5� -� G-60 S^ D�-� J �l/dD ��d`7G►rih�e, Le�' `%/tom _:3�J'/�%✓� �7%✓ l/,N.f�'° %Lf�� [/1�kR��.C�. 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 Mf the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is B r, of IIt -_—�G� Signed �/� /' Date Application Approved by Date e" Application Disapproved for the follows g reasons Permit No. Date Issued NJ � � l -_ .. , •�!�, ' '� ...�_� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF-BARNSTABLES MASSACHUSETTS 0[pprication for Oi-4pool *p$tem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel:15o. Assessor's Map/Parcel7-9 p`O 3 6 �� _ � � S 0 Q , Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 544", J 0 4.os , 6 ,N1' Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(/f�p Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures -� Llak Design Flow 3 �- gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date ' fi Title - Size of Septic Tank 1`5 i.> Type of S.A.S. Y Description of Soil Nature of Repairs or Alterations(Answer when applicable) GOV y"✓ J..e ,. Date last inspected: Agreement: v�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 f the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is B ' of Ith • Signed Date' Application Approved by Date /4- Application Disapproved for the following reasons Permit No. '47�Z Date Issued 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 Ste - 1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer �i/^� �s ' �wf Designer /1 .6 nC The issuance of this perrm allll�nottie'construed as a guarantee that the s yst9rg,w1H function as de/sig e�pol (� Date I '7(/l Inspector !/ ��i I/� 6A„ill � . V W -----— — — — -- -- — — — — --- A .� M Fee cS THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigpogar *p5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abanop.( ) System located at /1 �,n l/ .�1 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:Construction must be completed within three years of the date of this permit. Date: ��— Cf 7 Approved by _�� 513 - 03 1/669 ++ t NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH A D APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANSI hereby certi that the application for disposal works construction permit signed by me dated conce.*11ing the property located at lfyozk- 1�,91tiJi eets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 fe`t of the proposed septic system • There is no increase in flow and/or change in use proposed • There are ao varianc:s requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maodmtun adjusted groundwater table elevation. (Adjust the =undwamr table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 fee;of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) fee;above the ma.:cimum adjusted groundwater table e!evation, Please complete the following: A) Top of Ground Surface "Elevation(using GIS information) "C B) G.W. Elevation =the gh G.W. Adjustment . Dff ERE�iCE TWEE�i a.and B �- K, -. i t�� d SIGi+c : Deli;=: (Sketch proposed plan of s T e n on bac:<J. q:health folder.cct TOWN OF BARNSTABLE '. LOCATION S4(.jg,-c kA SEWAGE # 71/ VILLAGE SAC-P= ASSESSOR'S MAP & LOT D NSTALLER'S NAME & PHONE NO. u.ri5 ` /Z05, C-6-41 3&A-6,a3'7 S PTIC TANK CAPACITY ( S e v EACHING FACILITY:(type) .' 4( GNP ijuJ7/rt;�r(size) 9`X 37Xd'FiFa-) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER (/6i j BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: w i VARIANCE GRANTED: Yes No G 'i i :� v acap fq p ID ' O-CATION e SEWAGE PERMIT NO. VILLAGE INSTA LLER'S DAME i ADDRESS B U I L D E R OR ��0093 ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1 1 44 m J ram; .................... THE COMMONWEALTH OF MASSACHUSETTS "BOAR® OF HEALTH ....---..".............".--."..............O F..........................................--.--------.---------------..................--- Appliration for UiipngFal Works Tomitrudinaa an it Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: � � � k �� Loca o -Ad ess or o • .. --� � ---�_6z_- • � ��------------------------ _..... _�S._.D��'aM��..........------------.............__ ner Address W C.... Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) G, Other fixtures ......................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. _ Seepage Pit No--------------------- Diameter.................... Depth'below inlet.................... Total leaching area..................sq. ft. > Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................:....._._....._._.. Date..-----------------------------..... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ s' G%, Test Pit No. 2................minutes per inch Depth of Test Pit.............:...... Depth to ground water..........._............ 0 ------------------------------------•--------------------•......_.._... ----------------- ---------------------•-----•-•-..._....------------ .... VO Description of Soil........................................................................................................................................................................ ------------------------------------------------•-----------=------.:=---------....--------...................................................... OZL U Nature of Repairs or Alterations—Answer when applicable-----------fZV.6' _ -.__. ----=---..............................••••-•-•-••-------. �------••--- . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the,system in operation until a Cc tificate of C pliancc has been issued by the_boar-E6of health. Signed_ .L...... -......-•-•-•----•-•-- / Da e . Application Approved By.......---• '��' ----------------------- _.._ Date Application Disapproved for the following reasons------------------------------•--...---------•---------••-------------------.................................... y. Date is PermitNo.......................................................... Issued---------_----- )Date . No..... FRB............._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... ._.................OF................................. ...... _.. Apptiration for Uhapoii al Workii Toutitrnrtinn Vamit Application is hereby made for a Permit to Construct`( ) or Repair ( ) an Individual Sewage Disposal System at: ................_..9. 1. _.... �r 'a • -r— �y,) Loc�,,n!.A es's� c (j' = ......C. .. ................... .. er Address .............. ........•-----•--------.._............---...--------•-� ................... ........ ... Installer Address Type of Building ' Size Lot............................Sq. feet �--� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ----------------•------•-------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by a ..--••-----------••---•••••••....-•-----------•-•••-----------•-•••-_..... Date-------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x •-------------------..... 0 Description of Soil-------••------------------•-------------•----------•-••---------•-----.._..--------------------------•-----------..................................................... W U U Nature of Repairs or Alterations—Answer when applicable........_.. d ! �_ ,�'' :_`_ r__.�... U Pr---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Poa— hea th. Signed.. ---- -•-------------- - --------••--•-•------•- .......................... - Da Application Approved By-•-•--•----- r1. :._.., .= ..... ......�� ----•--•-•- '�Date Application Disapproved for the following reasons:---•-•---------•-----------••-•------------------------•--------------------•--•------------------........_...._ ....................................•----••-----......----------........--•-----------.......------........--------------------------...--------------------------------------------------------...--•--- Date PermitNo,,....................................................... Issued................--------------••--•--•---••-•-••••---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... V rtifiratr of (�ompliFan�e ti THIS IS TO CERTIFY, That the Ind, wa p Disposal System constructed ( ) or Repaired ( ) by.......•-•-----••-------...-•---------•----••--_• ---•---•--.._.... C Installer has been installed in accordance with the provisions of TITLE 5 of.The State Sanitary Code as described in the application for Disposal Works Construction Permit No-----e_.2_"'_��''°�'._____ dated---- .................. .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATFSF CTORY. DATE :,�.d ...C,�,leA' •-•- Inspector....._.. .....--"-�--•....................••---••---•-•--- THE COMMONWEALTH OF MASSACHUSETTS /BOARD OF HEALTH f� +rc !1/,,...OF....:.................../ �-`�'�`-"�:................. FEE....... -•--____--•--- Roposat n �k$ Ton try ion amit Permission is hereby granted_.. .. to Construct O or Re a r (� ) In vidual,+Sewag Disposal System atNo.............. --•---_- ....... -----.....- ` .............................. Street / )� ji••) as shown on the application for Disposal Works Construction Permit No....�.... ed................. ./ 1 ® •{•.r DATE----------------�—' 7 ter. Z��L Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 1