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HomeMy WebLinkAbout0194 SALT ROCK ROAD - Health t f' 1194 Salt i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name t information is BARNSTABLE required for MA 10/20/09 every 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: A, General Information When filling out forms on the computer,use 1. Inspector: P] only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A. BROWN INC Company Name r� P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 co sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of N Ti tie 5(310 CMR 15.000).The system: / ® Passes ❑ Conditionally Passes ❑ Fails 110 Needs Further Evaluation by the Local Approving Authority F' 10/20/09 pect ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �� t5ins 09/08 Title 5 Official Inspection Form:Subsul Sewage Disposal System•Page 1 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is BARNSTABLE required for MA 10/20/09 every 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: ® 1 have not found any information which indicates that any of the failure criteria described [ in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: CHAMBERS ARE DRY AT THIS TIME 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 P p ., approved by the Board of Health,will pass. Check the box for"yes", „y , no"or"not determined"try, N, ND)for the following statements. If not determined, lease explain. P p 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-O9jD8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 SALT ROCK RD l! Property Address GEMBORYS Owner Owner's Name information is required for BARNSTABLE MA every page. 6ty/Town State Zip Code Date of Date of 09 Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 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-09)08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ''Y o 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is gARNSTABLE required for MA 10/20/09 every page. CityfTown 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You.must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 Yz day flow 15ins•09/O8 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is required for BARNSTABLE MA 09 every page. City/Town 10 State Zip Code Datea o of f Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified labor atory,for fecal coliform bacteria indicates absent an d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria ar e 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•091D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 SALT ROCK RD Property Address f GEMBORYS Owner Owner's Name information is BARNSTABLE required for MA every page. Crtylfown 10/20/09 State C. Checklist Zip Code Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® R Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: . ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd'x#of bedrooms): 440 t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is required for BARNSTABLE MA 09 every page. Cdylfown 10 State Zip Code Datee o of f Insnspection D. System Information Description: ACCORDING TO AS BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON TAND D-BOX AND 2 H-20 RATED 500 GALLON CHAMBERS Numbe r of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 07-123 08-0 Detail: HOUSE IS VACANT Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yY 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is BARNSTABLE required for MA 10/20/09 every page. Edyrrown State Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records:, Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rY 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is BARNSTABLE required for MA 10/20/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: ACCORDING TO AS-BUILT CARD SYSTEM INSTALLED IN 2004 BY ROBERTS Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(9ocate on site plan): 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.):. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ®concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is BARNSTABLE required for MA 10/20/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑fiberglass ❑ polyethylene, El 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 t5ms•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis_ g posal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is required for BARNSTABLE MA 10/20/09 eve ry page. Clly/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK COULD USE PUMPING 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 t5fns-09M Title 5 Official Inspection Form!Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts AW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'f 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is BARNSTABLE required for MA 10/20/09 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 Orr 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.): BOX LEVEL NO LEAKAGE AT THIS TIME 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dls g posal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsu rface Sewage Disposal System Form No t for Voluntary Assessments 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is gARNSTABLE required for MA 10/20/09 every page. Clt Awn State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 0 leaching chambers number: _V00 GALLON ❑ 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.): CHAMBERS ARE DRY AT THIS TIME NO STAIN LINE PRESENT 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•09/08 Title 5 Official Insp ection 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 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is BARNSTABLE required for MA 10/20/09 every 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.): 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•09N8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is BARNSTABLE required for MA 10/20/09 every page. CRy/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•09108 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 15 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yr 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is gARNSTABLE required for MA 10/20/09 every page. Gt rr.wn 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: 14+ 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: 10/2009 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disp osal posal System•Page 16 of 17 t Commonwealth of Massachusetts ONE Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 194 SALT ROCK RD Property Address GEMBORYS Owner Owner's Name information is gARNSTABLE required for MA every page. Cltylrown 10/20/09 State Zip Code Date of Inspection E. Report Completeness Checklist i ® 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 tsins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION A SEWAGE# VII.LAGE �-(L.' �j'C��� SSESSOR'S MAP& LOT I INSTALLER'S NAME&PHONE N0, SEPTIC TANK CAPACITY LEACHING FACILITY: (type Y ( t (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 1 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) Edge of Wetland and Leaching Facility(If any wetlands exist Feet �. within 300 feet of leaching facility) Furnished by Feet I G L C'r8, r5 1 rely 3L Q � r13, ' TOWN OF BARN TABLE s LOCATION SEWAGE # VILLAGE t SSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 3Lam=/sn= t �- LEACHING FACILITY: (type), t ✓ (size) NO.OF BEDROOMS Q BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusied Groundwater Table to the Bottom of Leaching Facility Feet jV. Private Water Supply Well and Leaching Facility (If any,wells exist -on site or within 200 feet of leaching"facility); ,,� ­0 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) - Feet Furnished by r Imo. 1= 1 R y � U j� - No. Fee �. Y R THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppfication for Migozar bpotem Construction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �G 4 SCALT � 'RA Owner's Name,Address and Tel.No. Assessor's Map/Parcel 18Qzos CL W 1 f-4A -Tv,ornos 'SAMc Installer's Name,Address,and Tel.No. �.AP, Designer's Name,Address and Tel.No. by 6 ,�94 tAk s4 Type of Building: 2�1 04 4, Dwelling No.of Bedrooms L t Size -6S1;M0 sq.ft. Garbage Grinder(/ Other Type of Building No. of Persons ' Showers( Cafeteria Other Fixtures L yA-me Y ` kCTeiAE4 1S1A)k- . Lownim' Design Flow 350 gallons per day. Calculated daily flow 4 gallons. Plan Date w1'��3 \0 Number of sheets 1 Revision Date N Title 4 'C Size of Septic Tank !Ki m L LOG ReN AC4\k ype of S.A.S. t;7-� g t X X' �CtnC�n Description of Soil AM �1r.� 3� sc& &el�,kaQr3 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 ironmental Code and not to place the system in operation until a Certifi- cate of Compliance has be is "'e by t Bo d of th. Signe 10L Date Application Approved by Date _ 0 Application Disapproved for e following reasons Permit No. " � Date Issued 6 -d 9-O y �j y )� J � — J sy �� a � Fee i `., % Y w �� computer: r/ m r• V 'THE COMMONWEALTH OF MASSACHUSETTS Entered m co puce• Yes L' PUR IC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS apprtcat"on for Mtgogal *p!tem Con5tructton Vermtt Application for a Pernut=to Construct( )Repair Upgrade( )Abdon( ) ❑Complete System ❑Individual Components Location Address or Lot No. \q y S(sLT RCk W Owner's Name,Address and Tel.No. �gCf1s'4Ab� ,{N(a t YlC7iY�`J �C�-�� Assessor's Map/Parcel . ` Installer's�Name,Address,and Tel. Designer's Name,Address and Tel.No. 6 3 9(_ (o a 5 Type of Building: d (�?��°`� u� �9 Z°` 7 ' 1 qq Dwelling No.of Bedrooms Lot Size 35i a0U sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( Pi `Cafeteria(✓) Other Fixtures l.mvi)-Mg_Y, k,TCH Vj 51 a k ", Ln"ti'mY Design Flow 04044 2? gallons per day. Calculated daily flow SQ gallons. Plan Date L 15 \0 Number of sheets _Revision Date N h Title Size of Septic Tank �`txk.,T. t �C) 4iG� ��k 1�ype of S.A.S. � t� � x `�S( �! �, 1 t2d)C�n Description of Soil - .?R-d S CA, Nature of Repairs or Alterations(Answer when applicable) � e n• ++ 4 1 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title�5`&Pthe Errv�ironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been`iss5e' by this Board of 'ealth. Signed ..... Date (0-91�i-U Application Approved by I Date 16 .1 Qi—U C` Application Disapproved for e following reasons Permit No. I.X►L/— 32V Date Issued +. 1 . THE COMMONWEALTH OF MASSACHUSETTS . BARNSTABLE, MASSACHUSETTS Certtftcate of Compliance THIS IS TO CERTTII jY, that the On-site Sewage Disposal System Constructed( )Repaired ( ) Upgraded(� — t Abandoned( )by at ct y S ACk Y A10, r3:P,, 'N5 C,)D has .een constr cted in accordance with the provisions o T tle 5 and the for Disposal System Construction Permit No. r2W / dated 1)7 Installer Designer AA`F! The issuance of this permit sha�no b' cqn trued as a guarantee that t e syste UlffluSclioas designed. Date V Inspector No. 0 uo�f J- / ———— Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mtgoal *potent Congtructton Vermtt Permission is hereby granted to Construct( )Repair( )Upgrade( ) don( ) System located at ^ ,~c�`R S 19 LT U V/_ and as described in the above Application f%Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local°provisions or special conditions. Provided: Cons ction/`mus/t be completed within three years of the date Oft emmit. Date:_ � � / % Approved by c � /� TOWN F BARM TABLE LOCATION N SEWAGE # S SE SSO R &LOT S MAP . VILLAGE I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY V y (size) _ LEACHING FACU-ITY: (type NO.OF BEDROOMS BUILDER OR OWNER .PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility. (If any Wells exist Feet ,on site or within 200 feat of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within'300 feet of leaching facility) Furnished by t,► 6 14t, iq 1, 638 ..� Sep - 20-01 13 : 62 'BARNSTABLE HEALTH DEPT 50879063 4 r sns;o� NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOL,%TION TEST ANll SOIL EVALUATION EXENIPTION FORM �i hereby certify that the engineered pian signed by me a�tec concerning the property located at — meets all of ih i;I'ow�n; c,�tetia This failed system is con'necred to a residential dwelling only. Thee re no .ommerzia.! or business uses associated with the dwelling, The soil is ciassttied as CLASS 1 and the percolation rave is less than Or equal to > -n:-i.,tes per inch. The applicant may use hisconcal data to conclude this f3c; jr may :Dnduct ?re!imw.ary tests at the site without a health agent present • There :s no increase to flow and/or change in use proposed There are no vanances requested or needed. The boRom of the proposed leaching facility will not be located less han•fourteen 'I,j fee; aonve the maximum adjusted &roundwater table elevation. •Adiusc chc -oundwater cable using the Frimptor method when applicable) Please complete the following: ,. TOp -Di Cirouno Surface Elevation (using GIS information) _ 9 -L__ J� t,�.� �!Cvat:or.. _ •� •ad;ustment for inigh G.W. .3. _.. = .. �•�n - �TFFR,EN C F EETWEEN .\ d B E S:6'+fED — DATE: NOTICE 3asec j-oR t^e a1ove r.formacion, 3 reoair permit wil! be issued for '7edroom.s :dd�u-anal bedrooms are authorized to (he future witow en,tneerec :ept+. syae-n plans )r:uh!c:acl puccamp Permit Number: Date: Completed by: f HIGH GROUNDWATER LEVEL COMPUTATION Site Locatiti-o�n:_ �� ��],� p� ,�,7Fi l�� Lot No. _ Owner: Address: _��R,�Qj �� --, �� c ll Contractor: 011 ,Address: \ Notes: 0 � Q STEP 1 Measure depth to water table to nearest 1/10 ft. ..................................................................... ......... .Da e ��(T� mon /da /year STEP 2 Using Water-Level Range Zone and Index Well Map locate site,and determine: OAppropriate index well........................•.••........................ X OWater level range zone .......•..........••.........•...................•... STEP 3 Using monthly report "Current } Water Resources Conditions" i determine current depth to water level for index well mAh /yea STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) i determine water-level adjustment .•.•....•.....,•..•.••....•.•...•.•.......... t STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ...................................... 5� I; d Figure 13.--Reproducible computation form, 15 v Town of Barnstable • OpTME lq�, Regulatory Services O ; Thomas F. Geiler, Director 9� iM� �0�' Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 7/1/04 Designer: Shay Environmental Services Installer: Roberts Septic Service Address: 34 Thatchers Lane Address: 5 Trenton Street East Falmouth, MA 02536 ` Yarmouth, MA On 6/21/04 Roberts Septic Service was issued a permit to install a (date) (installer) septic system at 194 SALT ROCK ROAD, BARNSTABLE based on a design drawn by (address) , Shay Environmental Services dated 6/28/04 (designer) X X I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. (Insta le s Signature) moo` CABMEN WY � No 1181 9� 4 (Designer's Signature) ( tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form LOCAY'fON SEWAGE PERMIT NO. -VILLAGE I.NST*A LLER'S NAME & ADDRESS i 4 1 Z ,, BUILDER OR OWNER 0, L . U DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �� t' D c� � � �, ° - c � 1 r ' � � � , �, r i _y � .o s 44 THE COMMONWEALTH OF M.4SS'ACHUSETTS BOAR® OF HEALTH rW.�.-.......... oF. .��.,�. .L- --------------------------------- �,,,�� l -6 Aliptiration for Uiipusal Vorkfi Tonstrnrtinn Valuit ' Application is hereby made for 'a Permit to Construct ()<) or Repair ( ) an Individual Sewage Disposal System at: ..12o ,fit ®�® V A13 .....�� /�s .......................................... ..... - -----.. � ` Locatio Ad Vs s ¢l Lot No. ...l.1 C .� r L `S�.� If YV.��1 •1®,,�/� "AO .._._... ........... ... _..-•----•-•-._.... .................................................. x�c_- Owner Addre _ (�!G-�� --------------------------•-----------•- �(� (i/ .................................�t21✓ST�l�•LG.- I taller ;' Address Type of Building Size Lot----.......................Sq.Afeet Dwelling�No. of Bedrooms__._.___.______________________________Expansion Attic ( ) Garbage Grinder '4 Other—T e of Building ............................ No. of persons_________________________ Showers — Cafeteria a' Other fixtures .................................. W Design Flow_____________--- capacity.l.S4q__gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------1-------- Diameter__._.__(_ '_._... Depth below inlet.....G........... Total leaching area_41 ......sq. ft. Z Other Distribution box ( X) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. 1____i2......minutes per inch Depth of Test Pit......�-Z...... Depth to ground`water_.!✓/�!! VC. 44 Test Pit No. 2.:..............minutes per inch Depth of Test Pit_____�Z___.__ Depth to ground water__—X4;E_EN_ a t$' O Description of Soil....... "-- � aX lv/� Sda z r�•.5 D _ ®�' - �� �f CC _ �' W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -•--------------------------•------------------------------•---•--••----------------........--••--------•----------------------------------------------•------.........I Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systemin accordance with'` t the provisions of iITLi- 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 th bo rd of health. P �j Date Application Approved B __- ,t!.-f PP PP y -- --- d - ------ ---======- _'�_ ----------' Date Application Disapproved for the following reasons_____ ______/.......i�.................................................................................... .................•••-•_._.....---•----------•-------•---•••---•-----•----------•-•-••----...-..---------•----•-•--•--••-------••--••----•---•--••-•----------••-------••-•-----•-------•--•---•...•---•- Date PermitNo.......................................................... Issued-.......................................... Date Ivo................ ..... S._............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /...-O . ...................OF. A✓2 iJS..T A.3�^ .. ApplirFation for 11iipooFal Workti Tonstrnr#inn ramit Application is hereby made for a Permit to Construct ()<) or Repair ( ) an Individual Sewage Disposal System at _ v7' Z Snt... Roe-*- Ro4a i�Y2N.S /�3c-E �/I� � .... __.................. .7...- . --•--._..................__..._....... ----------------------------------------- --`1 ._.........._.. •- ............. Location-Ad r s -n�Lot No. v , (-l of C. L , V�N e +2 6�2/✓c - V1�. ' i4✓L dy o✓f/� �1F0 .. ---_....-------••--•• . --••-----•---•---•--•---•-•-••--••-•......•---- ........................................................ .................................. /A) f er ddre G /��/✓S T/+1�L C a --•----•- --••••---.......••--•--•----•-••- •--------- ------------------- -----•..........------.........._.............--•-----•--•......•--•- I staller Address Type of Building Size Lot............................Sq. feet Dwelling>-No. of Bedrooms............................................................................Expansion Attic Garbage Grinder Vej) Other—Type of Building No. of persons............................ Showers C4 YP g ---•-=---------------------• P ( ) — Cafeteria ( ) Q, Other fixtures ...................................................... Design Flow.............:::�...........................gallons per person per day. Total daily flow__•_-__�.'¢_V........................gallons. WSeptic Tank K Liquid capacity. �°O..gallons Length................ Width................ Diameter..........-..... Depth................ x Disposal Trench—No..................... Width.................... Total Length...._............. Total leaching area....................sq. ft. Seepage Pit No...........I......... Diameter.......f-!'__---- Depth below inlet.... ___......... Total leaching area...� ......sq. ft. Z Other Distribution box ( '?�) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1..... ......minutes per inch Depth of Test Pit...... _ ....... Depth to ground water. 4c. ...' =....�.. f=, Test Pit No. 2................minutes per inch Depth of Test Pit-----!..�..._.. Depth to ground water.-!V°'`_'t:__tN_�- a „ -----------------------_-------------•--•---.....------......;--•••--•-•-•----•••---.............•--••-----.._....-------------••--._.._..._...... O Description x Descri tion of Soil------�y � D ... 5 . i ...rt�5� 7PJ� <AP',1f dr L - .... .... _ ._-- _....- Wj ••--------------------••••----------------------------•--------------------------------•-•-----•-•--------------------- -------------•-------.....••••-•••---•---•--••••••............_................ 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 TITiE 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 ty bo rd of health. /-- 1- Date Application Approved BY••=.�c� 4L!/l •--- -------------- 3='? Y 7 r � Date Application Disapproved for the following reasons:........... -•-•••---••-•....................................................Dat.e............. .................•--...•--------•••••-----••-•••••---•-••--.....-••---••••-•-•--.._..._...---•-----••--••---...---•--•-•-•-••-••---•---•-•--•------••-•-••------•-•---------------------••--•••--•_---•- Date PermitNo..............••------••.....-•-••---•---•--••---------. Issued.................................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOAR"yD. OF HEALTH .. ................................t...1 ..OF...u/�2NST..........L.c . ................................. Trrtifiratr of TomptiFanrr T IS IS T CE TIFY, That the Individual Sewage Disposal System constructed (�r Repaired ( ) by;;. . ..... :. -......_... has been installed in accordance with the provisions of 6T 5 of The State"Sanitary Code as described in the application for Disposal Works Construction Permit No. %......I.I�_________________•-- dated.--r.... ....�_ '�.___.._._.__.__. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS,T UED AS A GUARANTEE THAT THE SYSTEM W14 FUN T, N SAT!§FACTORY. _ `� DATE........! .............. Inspector ---•-------------------. 7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................O F.. 2 N.�.r ..................................... Disposal Works T-Ponntrnrtio/n rranit Permission is hereby granted..��.A: i<U C L i Ng•--_-�,___V A,5 t+e-42, -------•-••-•-•------•••• •----------••-•-•••••-••••-•••...................... .... to Constr ct (14-) or Repair ( ) an Individual Sewage Disposal System 1 / at No...... • s% � ......... -f-7 7 ac i .--•--•--- oRD tJlS .dS C......�..._. e. treet as shown on the application for Disposal Works Construction r it n.......... Dated...'2_�_"7�.._.__._.:_. / eva"-A --------- - Board of H DATE........................................._..................... --------- ` FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ;. �T— COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED LEPECTION JUN U 2 2004 TITLE 5 TOWN OF BARNSTABLE OFFICIAL INSPECTION FORM -NOT FOR VOLU HEALTH DEPT. TS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A f , CERTIFICATION Property Address: 194 Salt Rock Road MAP Barnstable, MA 02630 PARCF-L. : - Owner's Name: Joe Lowell Owner's Address: LOT Date of Inspection: Maw 17, 2004 Name of Inspector: (Please Print) James M. Ford FAILED INSPECTION Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on 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 Needs Further Evaluation by the Local Approving Authority ✓ 'Is Inspector's Signature: oMkDate: May 22, 2004 The system inspector shall sub 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 d Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION"(continued) Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17, 2004 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. .Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has aseptic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank"and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level.in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: {The following criteria apply to large systems in addition to the criteria above) - Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ______gpd Oasis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Pumped every year-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: Qallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 12114178-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 22" Material of construction: ✓ concrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: -- Distance from top of scum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: -- How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The liquid level was above both the inlet and outlet tees and up to the cover. 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17, 2004 TIGHT or HOLDING TANK: None (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: eallons Design Flow: ¢allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above 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.): The D-box was under water. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I 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.): 1 dug down to the pit cover and liquid was filling the hole. 1 could not lift the cover. Liquid was approximately 1'+above the top of the pit. The pit was in hydraulic failure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM :Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. T1 �r• Ar I � Q / 13 y O L � 10 Page I I of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 194 Salt Rock Road Barnstable, MA Owner: Joe Lowell Date of Inspection: May 17. 2004 SITE EXAM Slope Surface water Check cellar Shallow wells ' Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and failed 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. 11 (( SECTION A -A ALL OUTLET PIPES FROM THE 10' min. from *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. Schedule 40 PVCw/2Charco�al�Odoarl)F4tx SEDIST F aox��K �12' CONCRETE COVER � ,"X" m �--- PROFILE VIEW OF LEACHING SYSTEM! �T Lsva FOR AT LEAST 2 Fr. Q I house to septic tank Existing Foundation plc tank oovers must be -� a ^ I ' St 3 - S'OUTLET 'ter-. ..i., y iT t within 6 in. of finished de SAS - E1J V� 100_EO `�:` KNOCKOUTS Grade over swot Tank - 99.50 Graft over D Box - 100.50 /�O�' +- r r/+ "r.en.i a,�.r ems. •fI r/ar'- r/+" rem"n..w■. s.s' r/ OUTLET � � . Ir S - 0.02 3 HOLE H-10 194sobellim S-0.10 DIST. Box 3' Ymdmum Cover op of SAS-Elev.=97.25 t55' _ EXIST. r OR GREATER S- 0.010 per foot • 4" SCH- 4D T 12' + W r^ sE� GAL.TA 30 1 C3 M C3 M CI PLAN SECTION CROSS—SECTION 0 o EffeelM ! f N w H-10 PVC TEE r�I � o o D@vth + one h = 29.5' FIAT F01111M2 f- ID e', ~� TO REER �oaTY 3. ' 5' 3.5' gREQUIRED 2952'73 HOLE H-10 DISTRIBUTION BOX6 M 0-Box tl 6 •—� O1 35' NOT TO SCALE SYSTEM PROFILE > 6 h.of 3/4"-1 1/2' o u u ' 12' N Effective L"th aM4fw.%&toyac«�y912110 a.*~Tm%wre c oompocted @tone o u Not to Scale - � > c c ' 500 - C H❑-20 IL LEACHINGABSORPTION UNITSTEM GGINS PRECAST GENERAL NOTES 6 In.of 3/4'-1 1/2' m compacted stone Bottom of Tent Hot* 1 EWv.-66.50 Not to Scale 1. Contractor is responsible for Digsafe notification NOTE: ALL CCfM!ONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE No 4Youndwatr Observed O 144' _ , and protection of all underground utilities and pipes. 2. The septic tank on j distri ution box shall be set level on 6" of 3/4 -1 1�2" stone. 3. Backfill should be clean sand or gravel with no -- stones over 3" in size. 4. This system is subject to inspection during installation PE R C 0 EAT I 0 N TEST _ _ — = 2675' by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance S L = 153.68' with Title V of the Massachusetts state code, the approved plan Date of Percolation Test: JUNE 18, 2004 i and Local Regulations. Test Performed By. Carmen E. Shay, R.S., C.S.E. — EDGE 0 -9 6. If, during installation the contractor encounters any Witnessed By. WAIVER (per BARNSTABLE B.O.H) EXCAVATOR: Shay Environmental Srvcs., Inc. --- -------_-------- - ----- soil conditions or site conditions that are different Percolation Rate: 2 MPI from those shown on the soil log or in our design � installation must halt & immediate notification be - --- -- ,' made to Carmen E. Shay - Environmental Services, Inc. Test Hole 7. No vehicle or heavy machinery shall drive over the No. 1 septic system unless noted as H-20 septic components. DEPTH SOILS ELEV. ,' 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. -0 100.50 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes- Sand 10. All solid piping, tees & fittings shall be 4" diameter Sane ; ,� 10 YR 3/2 Schedule 40 NSF PVC pipes with water tight joints. 0-_9- Ae �75 , 11. Municipal Water is Connected to The Residence and Abutting Loamy ,� Properties Within 150 Feet. Sand 10 YR 5/6 Be THE PROPERTY LINES ARE APPROXIMATE AND silt LOOMi COMPILED FROM THE SURVEY PLAN GENERATED BY 10 YR 6/2 i CAPE & ISLANDS ENGINEERING, MASHPEE, MA ENTITLED 10 YR 6/6 24'- 54 C, it "CERTIFIED PLOT PLAN OF Ill WARWICK WAY, MASHPEE, MA" r DATED JANUARY 24, 2004. IT SHOULD BE USED FOR NO PURPOSE Medium r Sand OTHER THAN THE SEPTIC SYSTEM INSTALLATION. r to YR 5/4 Perc #1 Ir r 144 C2 88.5 Depth to Perc: 54" to 72" LOT #12 179' LOT #14 WETLANDS ARE PRESENT WITHIN 200 FEET OF PROPERTY AS SHOWN. Perc Rate= 2 MPI � Groundwater Not Observed LOT #10 35,200 Square Feet +/- EXISTING LEACH PIT TO BE PUMPED & FILLED IN PLACE No Observed ESHWT ` O OR REMOVED IF FOUND TO BE NECESSARY TO INSTALL NEW SAS. _-ii ADJUSTED H2O Elev. = None O NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE FROM THE EXISTING LEACH PITS/CESSPOOLS TO BE DISPOSED � OF AS PER BOARD OF HEALTH SPECIFICATIONS. esi al ul ti n � ,C� N PROJECT BENCH MARK 6 y � TOP OF FOUNDATION LEGEND Number of Bedrooms: & B Broom E IS 1 G '�b Z� Garbage Grinder: No '\ �3 KKv ge C.Po ELEV. = 100.00 (Assumed) Leaching Capacity Required: OW Gal./Day (MIN. ER TITLE V) �� 104X1 DENOTES PROPOSED SPOT GRADE Septic Tank : - 2 x jib Gal./Day = JW0 gSAJSE EXIST. 1,000 GAL. Septic Tank. ' SOIL ABSORPTION AR A: Using percolation rate of <2 min./inch ' j Bottom Area: 0.74 gal/sq. ft. x 420 sq. ft. - 311 gallons �' DENOTES EXISTING Sidewall Area: 0.74 gal./sq. ft. x 188 sq. ft. gotroTs x 104.46 SPOT GRADE � Providing: - 450 gallons Use: (3) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH, PL PROPERTY LINE TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND EXISTING EXISTING PROPOSED CONTOUR caRAGE t9EDR00 2.75' OF WASHED STONE ON THE *BEDROOM — 96 — UNITS TO BE SEPARATELY PIPED AND TO BE SEPARATED 2' APART. HOUSE #1s4 — — — — — —97 EXISTING CONTOUR ' � I DEEP TEST HOLE & r � i PERCOLATION TEST LOCATION I 2-16' DIAM. ACCESS MANHOLES '� 26' 'I I I �"..-__...--'--'-� 6 FOOT STOCKADE F _ _ - -- 9 �\ Failed r � . _ `� Leach F`t�+ -- 92' ---- --- - _.1 t I j _ 0 1 (.` ; `� �; �1 Exrsr. 1 Doo 9a. �� 'aR--•-`��,T-' �� � tr`- � Septic Tank L- `\ N MIST _--_. .--- — 1 1 -- - _..-.• j r • I I, ` 1 OUT T THE ACCESS COVERS FOR 11E SEPTIC TANK F PROPOSED SEPTIC. S)- S t E lei U+I DISTRBUTION Box AND LEACHING COMPONENT .--r •-s --y r r; •' T- -.-,� SET DEEPER THAN 6 MCHES BELOW FINISHED 1 f-' PREPARED FOR�. `�' c y� ` -? - • GRADE SHALL BE RMSED TO 101111711111141 6' OF 1 • ; FINISHED GRADE. D...BO r T H O I Y�:A S E O W E E 1.-. STEEL REINFORCED PRECAST CONCRETE I / i - 1 1 PLAN AN VIEW INSTALL TUF-TITS GAS BAFTLES OR EQUALS � ' — t •- 1 '... i � AT I # 194 SALT ROCK ROAD i r 1 s 24' RETgYA$E CavETas 4" PVC r i % i t1 VENT _ -��, � _ �: ;. I TEST HOLE #1 ��s�_ram 1 • BARNSTARLE_ , MA ELEV = 1O0.5C� � �� ! rNrt r r r n.r I I2' "Ni" tea to ftAw e• � 1 I rr I � 11 105, 1 1 � ,.::�- (JUTIJ r - I L = 166.3 I �� 11 11 ,cN OF dlA — PREPARED BY: �r�.,r, I IJ�da`l.rr ]_T /� r " ' -r ! `.���� R = 1326.34' 11 °�� 4 �' (��l ARM EN Y ��!! I F 4'-0' nNn. � CD 1 -� 1 r UgiA/ dwth C) �� r 1` ' ----------------------------------1--------------------------- ----- ---------------------- " H ENVIRONMENTAL SERVICES, INC. ' �. r .S r•tr ��:f"i 1'•�..'.,�.-t�.yn, 1�..�.�.__ F - O. O P.O. BOX 627 i - - �7 A 0 20 40 50 rsTeR 7 R O UIV - O.A -�l EAST FALMOUTH, MA 02536 (40 FOOT RIGHT OF WAY) TEL/FAX : 508-548-0796 _ iYPIC AL10 QAU. N _SEPTIC, TANK - SCALE: 1 "=20' DRAWN BY: CES DATE: DUNE 28, 2004 NOT TO SCALE SCALE: 1 =20 PROJECT#SD595 FILENAME: SD595PP.DWG SHEET 1 Of- I f . ,.e�„ ,.,,.-, .. 11 A. .. ,.- , �. .. a ., .. .. ..s ., , ,. " &:,... : j�yy[ w..,�. , Z+fiM+.r wn.-.-. 77 - p , _ A ,- tt wm 11 ::. ,,. ., . - ..-. v:... .: ,. 1 .. �. " .., r , r I�dMv� r.�' 'k f f i. , - V ,: : ...- + :: -i' .. - .., - /� y� t' _ _ �y y - uy^ "%" 'El". N, a .. ti. : - .. -. _ - .: - , -.. _ ` - `! / tr . �. gg x. � 7 - - 11 .. ..- _ _ w :- r l7 _. i r . - .. .;r - 4 ti r�^ s ..., : , . 3. r - - .. R Tc e " I - a" - .: '. . r , Fi G .. .. - P" . v .. P, YtG Z r/In./,uay F : . y - '� v - _ i I ...,• •�N ` �,per. '.' - .• t . : _ :' Y -I !A Ate T E C ' - ,P - . 8 �? C. R S _ N to , . I ' 8. .. .. �� t . 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