HomeMy WebLinkAbout0141 SALT ROCK ROAD - Health 141 Salt Rock Road
Barristabte
A = 316 - 009
Commonwealth of Massachusetts 3l(0 069
a Title 5 Official Irispection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
U.1
,. 141*Salt Rock Road Assessor's Map:-316 Parcel:.9
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is gamstable MA ' 02630 ' January 14 2018
required for every ry ,
page. Cityrrown a 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, /
use only the tab 1. Inspector:
key to move your }
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Rapid Response '
Company Name °
155 George Ryder Road South
Company Address
I Chatham MA 02633-1621
City/Town State : Zip Code
508 364-0894. 1328
Telephone Number License Number.
d. .
B. Certification. .
1.certify that.l 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:
ED Passes 0 Conditionally Passes- 0 Fails
E Needs Further Evaluation by the Local Approving Authority
�J January 14, 2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection..lf the system has a design flow of
10,000gpd or greater, the inspector and the system owner shall submit the reportto the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable,'and the approving authority:
**'*This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will'perform in the future under
the same or different conditions of use.
t5ins.doc'•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage'Disposal System-Pagel of 17,
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Commonwealth of Massachusetts
Title 5 Official" Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141 Salt Rock Road Assessor's Map: 316 Parcel: 9
Property Address
Katherine L. Oconnor
Owner Owner's Name „
information is Barnstable MA 62630 January, 14 2018
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:
Inspector's Notes==> The septic system described herein'r is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in'Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination..
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 r20 years,old is available.
❑ Y ❑•N ❑ ND (Explain below):
• •
t5ins.doc•rev.6/16 Title 5 Official.Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
v Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 141 Salt Rock Road Assessor's'Map: 316 Parcel: 9 _
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is Barnstable MA 02630 January 14 2018
required for every ry
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. J
B) System Conditionally Passes (cont.):
Observation of sewage backu or break out or hi h`static water level in the distribution x❑ g p g box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box.is leveled or replaced .- ❑,Y ❑ N, ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of,Health).
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ `N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the�Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,,
b 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
c
t
Commonwealth of Massachusetts `
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `
,M 141 Salt Rock Road Assessor's Map: 316 Parcel: 9
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is Barnstable MA 02630 January 14, 2018
required for every rY
page. Citylrown State Zip Code Date of Inspection
B. Certification '(cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within_
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has aseptic tank'and SAS and the SAS is less than-100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
i
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
ri Liquid depth in cesspool is less than 6" below invert or available volume is,less
❑ ® than Y day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection "Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
141 Salt Rock Road -,Assessor's Map: 316 Parcel:�q -
Property Address
P _
Katherine L. Oconnor
Owner Owner's Name
information is required for every Barnstable MA 02630 January 14 2018
page. Cityrrown . ry State Zip Code Date of Inspection
B. Certification (cone.) t.
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 iSLbelow,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
t 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. ,
0 ® '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
A 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 i'n a nitrogen sensitive area (interim Wellhead Protection
El Area=IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat;
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.364: The system owner should_ contact the-appropriate
regional office of the Department. .,
t5ins.doc°rev.6/16 „ Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 5 of 17
Commonwealth of Massachusetts
u u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , 141 Salt Rock Road Assessor's Map:,316 T Parcel:`9
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is Barnstable MA 0263& January 14 2018
required for every ry
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 flowsin.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 breakout?
® ❑ 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
® El approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information .
Residential Flow Conditions: .
Number of bedrooms(design):, 3 Number of bedrooms (actual): 3
DESIGN flow 330 gpd
based on.310 CMR 15.203 (for example: 110 gpd x#of bedrooms).
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official; Inspecticn Form"'
orm a. "
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
141 Salt Rock Road Assessor's Map: 316 Parcel: 9
Property Address #, ,
Katherine L. Oconnor
Owner Owner's Name
information is required for every rY
Barnstable MA 02630'• J 'Janus 14, 2018
page. Cityrrown State _' . Zip Code Date of Inspection .
D. System Information. fi
Description:
Number of current residents �, z. 0 ,
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?n r' t : , *'❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readin s,"if available, last 2 years usa e d Y38 gpd
Detail: r ti
2017: 13,000 gallons, 2016: 15,000 gallons. # .
Sump pump? -� ❑ Yes ® No
Last date of occupancy _ 1 month ago
R Date.
Commercial/Industrial Flow Conditions: _ -
Type of Establishment:
r
Design flow(based on'310 CMRt15.203) - Y
r Gallons per"day(gpd)
Basis of design,flow(seats/persons/sq.ft., etc.): r
Grease trap,present? ❑ Yes ,❑, No
, r
Industrial waste hold ing'tank,present?• . ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system?, ❑ "Yes ❑ .No
Water meter readings; if,available: "
t5ins.doc-rev.6/16 T s Title 5 Official Inspection Form:`Subsurface Sewage Disposal Systemr Page 7 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 141 Salt Rock Road Assessor's Map: 316 Parcel: 9
Property Address F e`
Katherine L. Oconnor
Owner Owner's Name
information is ry
Barnstable MA 02630 January 14, 2018
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/user . - Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner's agent
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 pirevious inspection records, if any)
El 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):
1. . ..
r
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
u Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments_
141 Salt Rock Road Assessor's Map:-316 Parcel.9 - -
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is ,Barnstable MA 02630 -January14 2018
required)for every {
page. City/Town State . Zip.Code. Date of Inspection
D. System Information (cont:)
Approximate age of all components,,date installed,(if known) and source of information:
Age: 24+ years. Certificate of Compliance for a second leach pit was issued 12/22/1993 (Permit#93-
703 at Health Department).Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3
feet
Material.of construction:
r
❑ cast in ®40 PVC ; ❑ other(explain): .
Distance from private water supply well or suction line:
feet .
Comments(on condition of joints, venting,✓evidence of leakage, etc.).
No evidence of leakage or backup into dwelling.,
Septic Tank(locate on site plan):.,,,-
2.
Depth below grade: "
feet.
Material of construction:, `
®concrete ❑ metal'- ❑ fiberglass Elpolyethylene ❑other(explain)
If tank is metal, list.age-,
a years
Is age confirmed by.a Certificate of Compliance?(attach a copy of certificate) ❑ Yes 0 No.
85x5'x6'-1000
Dimensions:: gallon
Sludge depth: - 4 inches.
t5ins.doc.•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
91 . Title 5 Official Inspection Form r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141 Salt Rock Road Assessor's Map: 316 Parcel: 9 f
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is
required for every Barnstable MA 02630 January 14, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) `
Distance from top of sludge to bottom of outlet tee or baffle Winches
Scum thickness {' none
Distance from top of scum to top of outlet tee or baffle 10 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined? permit application
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time. Maintenance pumping is recommended within 2 years and every
2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and
functioning as intended. No evidence of leakage in or out was observed.
Grease Trap (locate on site plan):
:1
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
i
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GMi 5a�'� 141 Salt Rock.Road Assessor's Map: 316 Parcel: 9- - - -
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is Barnstable MA 02630 '�. January 14 2018
required for every rY
page. Cityrrown State. Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet'tee or bafflecondition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.): .
Tight or Holding Tank(tank must be pump
ed`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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts}
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 141 Salt Rock Road Assessor's Map: 316 Parcel: 9 '
Property Address
Katherine L. Oconnor
Owner Owner's Name y
information is Barnstable MA 02630 Janua 14, 2018
required for every ry
page. City/Town State.. Zip Code Date of Inspection
D. System Information (cont.),--
Distribution Box (if present must be opened) (locate on site plan):
4.
Depth of liquid level above outlet invert at outlet invert
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.): ,
No adverse conditions observed. .
_
m .
-
Pump Chamber(locate on site plan):
Pumps in working order: ❑ 'Yes . ❑ No*
Alarms in working order: n ❑ Yes ❑ No"
Comments (note condition,6f pump chamber,:condition ofpumps•and appurtenances, etc.):
* If pumps or alarms are not in working order,system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why: :
t5ins.doc-rev.6/16 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
141 Salt Rock Road Assessor's Map:`316 Parcel: 9
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is Barnstable ' MA 02630 January 14 2018
required for eve ry
4 every
page. Cityrrown State. Zip Code, Date of Inspection,
D. System Information (cont).
Type:
® leaching pits number:,, 2-
El leaching chambers number:
❑ ,leaching galleries number:
❑ leaching trenches number, length:
4
❑ leaching fields number, dimensions:
❑ overflow cesspool: number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.): : .
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed: Water was observed to'pass through to the soil absorption system in a rapid and
unobstructed manner. Water`meter readings show an avarage of 38 gallons per day consumed over
the last 2 years. .
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
•r
Materials of construction
Indication of groundwater inflow '❑ Yes ❑ No
l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
141 Salt Rock Road Assessor's Map: 316 Parcel: 9
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is required for every Barnstable MA 02630 January 14, 2018
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts'
F v Title 5 Official Ijnspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 141.Salt Rock Road Assessor's Map. 3'16 .Parcel: 9
Property Address r
Katherine L. Oconnor
Owner Owner's Name
information is required for every Barnstable ' MA' :02630 January 14, 2M
. ''' .
page, City/Town State, Zip Code Date of Inspection
D. System Information (cont:)
Sketch Of Sewage Disposal System: Provide a view of the sewage'disposal system, including ties to
at least two permanent.reference landmarks or benchmarks.Locate all wells within 100 feet. Locate
Where public water supply enters the building Check one of the boxes below:
❑ hand-sketch in the.area below
drawing attach
ed.separately.
P y 7.
AT
SEPTIC INFO
�� ,THIS .SKETCH IS . .
E C O- E C H• BEST. VIEWED IN' .,.
COLOR.FORMAT
}
i ►L- OCA T90l S:, II
EXISTING
-OF SEPTIC COMPONENTS
DWELLING =DISTANCES IN DECIMAL"FEET
WA TER
LINE
1 9- . 28•
A 8 .
2 23 26
3 29
. 26
i
4 46. 48 . .
1000 GALLON. —
SEPTIC TANK.r LEACH Q
PIT 3
D=eOX Q NOT
QSCE
LEACH r y
PIT
. . : .SALT ROCK:: ROAD O R�SPo
508 364-0894
t5ins.doc•rev.6116 „ '' Title.5 Official Inspection Form;Subsurfaze Sewage Disposal System Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 141 Salt Rock Road Assessor's Map: 316 Parcel: 9
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is required for every Barnstable MA 02630 January14 2018
_
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: 2 fe eett
-
Please indicate all methods used to determine the high,ground water elevation:
❑ Obtained from system design plan's on record' -
If checked, date of design plan reviewed: } Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS) ;
❑ Checked with local Board of Health -explain:
,
❑ Checked withflocal excavators, installers-`(attach documentation)
® Accessed.USGS database -explain: "
Barnstable GIS Department records
You must describe'how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 20 feet above
groundwater table
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
Title 5 Official 'Inspection Form
Subsurface Sewage Disposal System Form - Not for Vol u ntary,Assessments
141 Salt Rock Road Assessor's Map: 316 Parcel: 9 k4
Property Address
Katherine L. Oconnor
Owner Owner's Name
information is Barnstable MA 02630 January 14 2018
required for every ry
page. Cltyrrown 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.doc•rev.6/16 < Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 17 of 17
�` �� �✓ TOWN OF BARNSTABLE N
LOCATION SEWAGE #
VILLAGE 34gt ASSESSOR'S MAP & LOT / 00
INSTALLER'S NAME.& PHONE NO. /� r,tZe 3 C d
SEPTIC TANK CAPACITY 0 (-' C3 ln� d
LEACHING FACILITY:(type) .d t 4A, (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No... ��✓ Fxa..... .- lJ
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
Barnstable Conservation DeaddinbOt BOARD OF HEALTH
r �FZTOWN OF BARNSTABLE
S' ned We
Appliration for Bi,npoiial Work.5 C on.6trurtion matt
Application is hereby made for a Permit to Construct ( ) or Repair A an Individual Sewage Disposal
System at:
....4�.....................................................................................
Location- ddre or.. o.
... •----------------------•-•-•--•-•--...-•----------------. . .----•-.......G.......-•---•---.........
Owner Address
-_----------------- ----------------------------- ------------------------------------------------------
Installer Address
VType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms.__. ......................:............Expansion Attic ( ) Garbage Grinder ( )
PL, Other—Type of Building .... No. of persons............................ Showers ( ) — Cafeteria
Other fixtures ............................... . .
W Design Flow............................................gallons per person per day. Total daily flow_.------------------------------------------gallons.
WSeptic Tank—Liquid capa6ty/J._424).gallons Length________________ Width...-_-__-_-_---. Diameter---............. Depth................
x Disposal Trench—No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No./.-_/.0P6 Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( c�— Dosing tank ( )
Percolation Test Results Performed bY-------------------------------------------------------------------------- Date........................................
Test Pit No. 1----------------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........................
a ---•----•-----------------------•------•-•------------•-------•--•••---•-----------------..................-•-..............-•------••--------....----------�
0 Description of Soil................................................................................................... ----------------•------------------ ................................
x
W ------------------------------------------------------------------------------------------------------------
/ d�. j L
U Nature of Repairs or Alterations=Answer when applicable.__-_ _... / 1......... '¢.....!2...p
--------••••-------------------------•-•-••-------•------------------------•-•----•--•------•---•••.•------••------------------------------------------......----•-•-----•--------------------.....-•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia cC s been issued by the board of health.
12
Signed .......................�
Dace
Application Approved B
Application Disapproved for the following reasons- ---------------------- ----------------------------------------------------------------------------------------------------------
- - --------------------------------------------------------------------------
Dare
Permit No. 13., ' ................ Issued ..... - ----------yam-- .-- -�.—�..
Dare r
Fxs.... �J'f^�
THE COMMONWEALTH OF MASSACHUSETTS
J s BOARD OF HEALTH
-DTOWN OF BARNSTABL.E
Appliratiou for Diti-V l ial Works C owitrurtiou rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair A an Individual Sewage Disposal
System at:
Location-Address
or )Ot No.
Owner Address
Installer Address
UType of Building Size Lot............................Sq. feet
.. Dwelling—No. of Bedrooms.-_._:.....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building F r .f_ ._... No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------•----- ------.
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity�0_,2J_gallons Length---------------- Width---------------- Diameter-._.---------- Depth--------------_
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No. -.-._.�C>.vU Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( e)- Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I.-.-----_-_---minutes per inch Depth of Test Pit.................... Depth to ground water......................
.-
L14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil........................................................................................................................................................................
U \
�l
................................................................................................................... ...`. ... ......._................___-_-........ ......._....._...........
U Nature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant-e has been issued by the board of health.
J _ ........................................Z -
Signed -- - ------- r '---- -- --------------
Dare
Application Approved By .. i<�� �'-..4�' ----------------------------------------------------- 1�`' .
Application Disapproved for the following reasons- ------------------------
r
. ..................................... .. ..............................--............ ..... ................................................. .. . ........................................
Permit No. Issued ..--. -- ----_.�. ._....:......................
Dare
7�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Te r#ifirtt#E of Graptianre
THIS S T ; CERTIFY, hat the Individual Sewage Disposal System constructed ( ) or Repaired
by ........ = -
at .......J.y ..........514Z ............... t a.G am` ---- ---- - ----------- / -- _...
has been installed in accordance with the provisions of TITLE ,off The State Environmental Code as described in
the application fcr Disposal Works Construction Permit No. -�/.''� -�--_--- dated .,' - .-"- -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL UNCTION SATISFACTORY.DATE - Ins ectoz �...�� --- -------------------------------------
--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.ry No. TOWN OF BARNSTABLE
/ FEE. :.
Utsposal Workii Tanotrudion rruti�
Permissionis hereby granted---------- ---------------------------------------------------------------------------------------•---
to Construct ( ;, or Repair ( L--� an Individual Sew• e Dispo al System
atNo.. /. /......r ��?G,�s� `c---•......._ /_. ---------------------------------------- -----•----------------...........
Street � -- ! ` �
as shown on the application for Disposal Works Construction Permit`No._-_-__---'_._____.�•ated_----------------------------------------
Psi 1/
�'
/ � Board of Health J
DATE----•-----------...................... -----•-•-•----------•--------------------
i
FORM 36508 HOBBS R WARREN.INC..PUBLISHERS
No... / Fsa.... 2/
THE COMMONWEALTH OF MASSACHUSETTS
__BOARD O HEALTH
�(
Appliration -fur 43itipwial Worko T trurtimn Punift
Application is hereby made for a Permi to Co uct ( qr Repair ( an Individ Sewage Disposal
System
Locatio - d ess or Lot o.
.... ...... .' - • -c_-___-•---' _. __ ___•__.. ....�_......J�..4r
................ .. .................. ...............................
O r -Ad ess
W ,e
Installer Address
d Type of Build i / Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms---------- __-_______Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures .._ _
- •- ------------------•----.-----------------------------------------•-•------ ------------ ---
Design Flow.................. ..... . ............ al ns per person per day. Total daily flow......, ------------gallons.
W 11
R; Septic Tank t Liqui capacity _______ ons Length................ Width----------- _.. D' meter---............. Deptli__--___.__-_-...
W Disposal Trench—N ..................... Wid h._.__..... ._,_ 1 n -_ T lgleaching area--------------__---Sq. ft.
x ,/��
Seepage Pit No.-.-_------__-- Diameter...: � e bel let. ........... .. 1 leaching area._--____________sq. ft.
z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed b
W Y-------- ----------------------------------------------------------------- Date----------------------------
,� Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water_.._____-__-___-__-.__..
wTest Pit No. 2................minutes per incAlDle of Test Pit-_....._......_____. De to ground water_-__________.___-.__.Ix _________________________________ _________•____ .._...__.. ....... _-•__-_ -__-_-____.--•-____.--___-_______-_____ F-_-______.._.O Description of Soil----------------- ---------� ` ..o -
U ------------------------------------------------•-•--•-• -" --- --- --'---- ------ ---- -------
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 Article \I of the State Sanitary Code—The undersigned further agrees not to place the system it]
operation until a Certificate of Compliance has b n issued the boa of health.
e
ned....- ------ -------------------------------------
--------------------------------
D
Application Approved BY------------ at ��
Application Disapproved for the following reasons-------------------------------------------- --------------------------------------------------•-----------__......
-------------•----------------------•---------------•-----...--------------------------••----------------•••--•---•••---------------•-•----•---••-•--- -------------------------------------------------
Date
Permit No.......................•---••----•-•----•••-•.......... Issued.....4�;_ .=.57-7
Date
No.._ ,r Fsa..... ,:..
THE COMMONWEALTH OF MASSACHUSETTS
BARD QF2HEALTH
------OF...-... ............. ................................. .
Applira#ion for Diipniitt1 Works T i#rur#ton Vami#
Application is hereby made for a Permi to C r Repair ( an Individwj Sewage Disposal
System
� ----- ------ --- *..
as ocatipo . rd• �y or Lot
d e s
A!____________ _ __
.�.____......__.___
Installer- Address
d Type of Build Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms---• .�*--------------------------Expansion Attic ( ,) Garbage Grinder ( )
pa, Other.—Type of Building ----__-__--- _-•---_. --- No. of persons............................. Showers ( ) — Cafeteria ( )
Q' Other fixtures _ r*'�►
W Design Flow al ns per person per day. Total daily flow.-.... ...gallons.
WSeptic Tank Liqui capacity .__•. ons Length________________ Wi th_. __._... .:.. D' meter_.-___ ________ Depth. ....__. ._
x Disposal Trench—N - -------------------- "lid i._ 1 T bleaching area -. -... _. __._sq. ft.
Seepage Pit No ___ _____________ Diameter_ __ ep bell let. _.... __. _ '1 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------------_-_-..____-
Gi, Test Pit No. 2_---------------minutes per inch Deli of. Test Pit.....__._.._..------ DeA to ground water__.__.-_-_-.._-.__-.-__.
a+ ------- •---- _, ... --- s
O Description of Soil------------------ ------ 'r -- s = ----- - -----
x -------------•.. ..-•---••-- '"v - ... ----- t�,r..y.:
_.:-=-- -'------=---------------------------------------------------------------------------------------------- -------------------=------------------------------
U Nature 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 Article XI of the State Sanitary Code—The'undersigned further agrees not to place the system in
operation until a Certificate of Compliance.has be n issued the oa of health.
011
Z'Sin -- ............................ ...••-- --------------------------------
Application Approved By...
/"- at
.-f-
Application Disapproved for the following reasons:----•-------------•------•-----•----- ---------•-----------=-----------------
•---------•-•--•-------------------------•--•-----•-••---------------•-•------------•--------------------------------------•-•--•--•-•------------•-••-=-----------•-----•--•---------------------•-----
Date'-
Permit No.......................... - Issued----------- ....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
{
BOARD Oh HEALTH "`""r-�___
......... ...
:t-r � 1-fIra#. of Tomphaurr
S 7 T ;METTIFN , Tha .t _ vi u Sewage Dis os 1 System constructed or Repaired ( )
b
at - ------------•---
------- -- - -------- - -- -
has. een installed in accordance w the pr islons of Article of- e State Sanitary Cocle a described in the
application for Disposal Works.Construction Permit No.__._._..1 _ _ _____________ dated. j. _ -__ ......_ ..__....
THE ISSUANCE OF THIS !CERf FICATE SHALL. NOT BE CONSTRUED AS A GU R N EEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector-------------------------------------------------- .................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
.r.... . .........OF.,No._ .. �. FEE••-- ..........
Permissi ereby" granted-.,....... --- ------------ -----
to Cons r ) or Rep ) Vndivid S wage I pos. yst �
at No..
as shown on the a lication for Disposal eWorks Constructio s _ Dated___ qq-Ay
PP P fi : t - -
d .
______ ________ ... ._ _
? and of Health - -----•••- •---•-••�
DATE. t�' 'ts`
F, • �jll �
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ��'�. ell
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