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Home My WebLink About0086 SCUDDER'S LANE - Health (2) 86 SCUDDER LANE,BARNSTABLE o ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M-258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02630 October 2, 2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, Ij use only the tab 1. Inspector: key to move your cursor-do not Troy Williams use the return Name of Inspector key. Troy Williams Septic Inspections Company Name 19 Hummel Drive Company Address South Dennis MA 02660 City/Town State Zip Code (508)385- 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority October 2, 2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. O I t5ins•3113 Title 5 Official Inspection o Subsurface Sewage Disposal System-Page 1 of 17 t 4 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M-258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder s Lane Barnstable MA 02630 October 2, 2014 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: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I S � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder s Lane, Barnstable MA 02630 October 2, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 T t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..°' 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is 86 Scudder's Lane, Barnstable MA 02630 October 2 2014 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: t 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 %day flow t5ins•3/13 Title 5 Ofrdal Inspection Forth:Subsurface Sewage Disposal System•Page 4 or 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 86 Scudder's Lane, Barnstable M-258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder s Lane, Barnstable MA 02630 October 2, 2014 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 t Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�" 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is 86 Scudder's Lane Barnstable MA 02630 October 2 2014 required for every � , page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'Y 86 Scudder's Lane, Barnstable M-258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02630 October 2, 2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 13=132,000 gals. g ( y g (gp ))' 12=131,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date CommerciaUlndustrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins•3113 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 86 Scudder's Lane, Barnstable M-258 P- 19 Property Address Helen Boocock Owner Owner's Name information is 86 Scudder's Lane Barnstable MA 02630 October 2 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): N/A General Information Pumping Records: Source of information: Last pumped in 2013 and every 2 years per info from owner. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M-258 P--19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02630 October 2, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Approximate age of all components, date installed (if known)and source of information: Tank, d-box and leaching were installed on 6/23/87 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"+feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: 30"with steel covers to grade. feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal list age:g years i Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'X10.5'X6' 1500 gallon Sludge depth: 4" t5ins•3/13 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 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is 86 Scudder's Lane Barnstable MA 02630 October 2 2014 required for every , page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2'8" Scum thickness none Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" probe/measured 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.): Pvc inlet and concrete outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/Afeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder s Lane, Barnstable MA 02630 October 2, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owners Name information is 86 Scudder's Lane Barnstable MA 02630 October 2 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order with flow to both pits. 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.): N/A * 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: l5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M-258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder s Lane, Barnstable MA 02630 October 2, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-8'X6' pit with stone ❑ 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.): Leach pit#2 was found with water level 5.0' below inlet invert with walls found clean above water level. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Pit # 1 was found with water level up to inlet line. Covers are steel to grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r > Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder s Lane, Barnstable MA 02630 October 2, 2014 page. Citylrown State Zip Code Date of Inspection D. System Information (coot.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•3/13 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 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02630 October 2, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately D r C. O O 3 / OL 30 y � ygl �� 66 ` L Z �It Lz yZl t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M-258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02630 October 2 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 16.0'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/23/87 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Past inspection on file. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: SDW 252 Zone A 47.2' 1.3' adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 14.0'. Hand augered 2' below bottom of leaching with no water found at a depth of 15.5'. Groundwater adjustment at the time of inspection was 1.3'. Bottom of leaching at 13.5'was found not to be located in the high groundwater elevation at the time of inspection. USGS groundwater map shows groundwater at 18.0'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 or 17 t r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M-258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02630 October 2, 2014 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. e SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ^�/'—)� I (size) �� NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of Ic illty) Feet Furnished b V\ i \ Q� d • y Al kn 00 . J f y Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 86 Scudder's Lane, Barnstable M -258 P - 19 Property Address Helen Boocock r# Owner Owner's Name information is required for every 86 Scudders Lane, Barnstable MA 02630 November 28, 2012 page. Citylrown State y—Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information fin the computer, formsut /1 on the computer, [Ply use only the tab 1. Inspector: key to move your cursor-do not Tro Williams use the return key. Name of Inspector Troy Williams Septic Inspections ITV Company Name 19 Hummel Drive Company Address South Dennis MA 02660 City/Town State Zip Code (508) 385- 1300 S1682 Telephone Number License Number J B. Certification I certify that I have personally inspected the sewage disposal system at this address and that theme 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 oh-site sewage disposal systems. I am a DEP approved system inspector pursuant to Section°115.340mof Title 5(310 CMR 15.000). The system: C:) r— ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority J November 28, 2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11110 Title 5 Off In coon Form:Subsurface Sewage isposal System•Page 1 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M -258 P- 19 . Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02630 November 28, 2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): N/A t5ins•11/10 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 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is 86 Scudder's Lane, Barnstable MA 02655 November 28, 2012 required for every page. Cityrrown State Zip Code Date of 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): N/A ❑ 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):, N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02655 November 28, 2012 page.e. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A 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 0 ® 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 %day flow t5ins•11/10 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 86 Scudder's Lane, Barnstable M-258 P - 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane Barnstable MA 02655 November 28 2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last.year NOT due to clogged or obstructed pipe(s). Number of times pumped: An portion of the SAS cesspool or privy is below high round water elevation. ❑ ® YP P P Y 9 9 ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ . ® 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is 86 Scudder's Lane Barnstable MA 02655 November 28 2012 required for every + page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane Barnstable MA 02655 November 28, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: b Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 11=129,000 gals. g ( y g (gp ))' 10=133,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins-11/10 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 wM , 86 Scudder's Lane, Barnstable M -258 P - 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder s Lane Barnstable MA 02655 November 28, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: Last pumped in 2011 and every 2 years per info from owner. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M -258 `P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02655 November 28, 2012 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: Tank, d-box and leaching were installed on 6/23/87 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"+feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: 30"with steel covers to 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: 6'X10.5'X6' 1500 gallon Sludge depth: 411 t5ins•11/10 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 86 Scudder's Lane, Barnstable M -258 P - 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02655 November 28, 2012 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 2' 8" Scum thickness thin layer Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and concrete outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is 86 Scudder's Lane, Barnstable MA 02655 November 28 2012 required for every + page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition,-structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: , ❑ concrete ❑ metal ❑fiberglass "' ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/A 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.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments µM 86 Scudder's Lane, Barnstable M -258 P - 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02655 November 28, 2012 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order with flow to both pits. 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.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 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 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02655 November 28 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number:. 2-8'X6' pit with stone ❑ 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.): Leach pit#2 was found with water level 5.5' below inlet invert with walls found clean above water level. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Pit # 1 was found with water level up to inlet line. Covers are steel to grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration r N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17. Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M-258 P - 19 Property Address Helen Boocock Owner Owner's Name required fo is 86 Scudder's Lane, Barnstable MA 02655 November 28, 2012 required for every page.. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M-258 P - 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02630 November 28, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 6F 2 3 C 3 : 3o' 9 9 V 3 31 ' (Sins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection form e Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M-258 P - 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02630 November 28, 2012 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: 16.0'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/23/87 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Past inspection on file. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: SDW 252 Zone A 47.5' 1.6' adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 14.0'. Hand•augered 2' below bottom of leaching with no water found at a depth of 15.5'. Groundwater adjustment at the time of inspection was 1.6'. Bottom of leaching at 13.5'was found not to be located in the high groundwater elevation at the time of inspection. USGS groundwater map shows groundwater at 18.0'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Scudder's Lane, Barnstable M -258 P- 19 Property Address Helen Boocock Owner Owner's Name information is required for every 86 Scudder's Lane, Barnstable MA 02655 November 28, 2012 page. City(rown 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 t t5ins-11110 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r DATE• 1 /1.5/01 ---- ,. f PROPERTY ADDRESS:86._Scudder Lane" nst ss------- ---02630 ---------------- On the above date, I Inspected the septic ,system at the above address. This system consists of the following; 1 . 1 -1500 gallon septic tank. 2. 1 -Distribution box. 3 . 2-1000 gallon precast leaching pits. Based on my Inspectlon, I certify the following conditions: 4 . This is- a title five..septic system. ( y78_ Code ) 15. The septic system is in proper working order at the present time. r- 6. .'# '1 leaching pit -has 12"'of waste water. 60" below invert pipe. # 2 Leasching pit is dry• at the present time. SIGNATURE Name; Company, Jca•�h_P �, Nacomber_b Son , Inc . Address;_ Box_66— --Cantervi11a Ha ,_02632-0066 Phone;___ ------- THIS CERTIFICATION DOES NOT CONSTITUTE A OVARANTY OR WARRANTY J6SEPH P. MACOMBER & SON, INC. Tanks•Cesspools•Leachflelds _ Pumped G Instsllsd Town Sewer Conneotlons P.O. Box 6y75.3338erY1114, M 102632.0066 RECEIVED JAN 16 2001 TOWN OF BARNSTABLE HEALTH DEPT. - -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 86 Scudder Lane Barns a e,Mass. Owner's Name: Roger Boocock Owner's Address:Box 851 Barn stable,Mass_ 02630 Date of Inspection: 1 /1 5/01 Name of Inspector:(please print)Joseph P.macomber Jr. CompanyName: J.P.Macotn er & Son Inc. .Mailing Address: Box 66 ; Centerville—,Mass. 02632 Telephone Number: 508-775-3338 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 • Fails Inspector's Signature: i 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. Notes and Comments ` ****This report only describes conditions the time of inspection and under the conditions of use at that ' time. This inspection does not address how the system will perform in.theJuture.under.the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 'Pate 2 of I 1 • • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) „ Property Address: 86 Scudder"Lane Barnstable,Mass. Owner: Roger Boocock Date of Inspection: 1 /1 5/01 Inspection Summary:'Check A,B,C,D or E/ALWAYS complete all of Section D A �SystemZsses- 1,tt� 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: .w • 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. ,Q10 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; iL1 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 Scudder Lane Barnstable,Mass. Owner: Roger Boocock Date of Inspection: 1 /15/01 C. Further Evaluation is Required by the Board of Health: A 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: ,1,?A 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 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 I of a public water supple. &�L 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 buh50 feet or mope from a private water supply well". Method used to determine distance �L�GGd "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: c)n t- 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 Scudder Lane Barnstab e,Mass. Owner: Roger Boocock Date of Inspection:1 /15/01 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.lev6,' the dis bution box above outlet invert due to an overloaded or clogged SAS or cesspool ,oc�.i,�� J�7r ' _ � Liquid depth-inoesspe- 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. 7 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.) �fL(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 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• 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 _ __I/the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the.system is considered a significant threat,or answered.- "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B • CHECKLIST Property Address: 86 Scudder Lane arns a e,Mass. Owner: _Roger Boococ Date of Inspection: 1 15/01 Check if the following have been done. You must indicate`yes"or"no"as to eachf 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 component i,-okluding 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 Cis at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 86 Scudder Lane Barnstable,Mass. Owner: Roger Boocock Date of Inspection: 1 1 5 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 9V2M Number of current residents: Does residence have a garbage grinder(yes or no): M0 Is laundry on a separate sews system (yes o no): _ [if yes separate inspection required] Laundry system inspected&or no): Seasonal use: (yes or no): �/", Water meter readings, if available(last 2 years usage(gpd)):Ai%,4 MIZALA4 '�iv/iRy Sump pump(yes or no): Auq ` Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: 41,4. Design flow(based on 310 CMR 15.203): Vlf gpd Basis of design flow(seats/persons/sgft,etc.): X119 Grease trap present(yes or no): ti"h Industrial waste holding tank present(yes or no):A✓A Non-sanitary waste discharged to the Title 5 system(yes or no):AO Water meter readings, if available: Last date of occupancy/use: 04 OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 7 JFlF /ipy� F 7-917-/�* Q 4:,,' Was system pumped as part of the inspection(yes or no): If yes, volume pumped: C_gallons -- How was quantity pumped determined? ti Reason for pumping: .Vi4 TYP )Z OF SYSTEM _ZSeptic tank,distribution box,soil absorption system Single cesspool ,V,L Overflow cesspool . Privy �&Shared system(yes or no)(if yes,attach previous inspection records, if any) 4?A Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank AIA Attach a copy of the DEP approval , 4t� Other(describe): �✓� Approximate aee of all components, date installed if know"an ounce of i formation: Were sewage odors detected when arriving at the site(yes or no):�f� 6 Page 7 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:86 Scudder Lane Barnstable,Mass. Owner: Roaer Booeock Date of Inspection: 1 11 5.1 o l e ' BUILDING SEWER(locate on site plan) Depth below grade: ell Materials of construction: ast iron _j,.140 PVC./,4other(explain): AIVI Distance from private water supply well or suction line: /D 9- Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight. No evidence of leakage stem is vented through the You e vent. /500 SEPTIC TANK: locate on site plan) Depth below grade: Material of construction: _/Zconcrete4 meta 14!d_fiberglass4&2poIyethyIene " �bther(explain) If tank is metal list age:d.�Z Is age confirmed by a Certificate of Compliance (yes or no):Ai9 (attach a copy of certificate) J Dimensions: Sludge depth: p Distance from top ofs)udge 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 bottp!n Df outlet tee or baffle: How were dimensions determined: 6� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels -as related to.outlet invert, evidence.of.leakage, etc.): Pump the septic tank+ Piero 2 you Ihlet & outlet tees are ; n place:The -tank-is -structurally sound- and -,haws no Pv; riPnc-P of leakage.Liquid level at the outlet invert is fifty one inches. GREASE TRAP:A-koocate on site plan) Depth below grade:Af/ Material of construction:X4 concreteiM metaid� fiberglassAL,4polyethylene4,)tother (explain): A14 Dimensions: Wh Scum thickness: Distance from top of scum to top of outlet tee or baffle: Av/w Distance from bottom of scum to bottom of outlet tee or baffle:. A 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.): Grease trap is not present./ 7 Page 8 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 Scudder Lane Barns a e,Mass. Owner: Roger Boocock Date of Inspection: 1 /15/01 TIGHT or HOLDING TANK:.r,e, dtank must be pumped at time of inspection)(locate on site plan) Depth below grade:_'� n Material of construction: s),f concrete y�metal�liq fiberglass A/ polyethylene v.,Y other(explain): A111 Dimensions: AM Capacity: ,y,4 gallons Design Flog+: d)A gallons/day Alarm present(yes or no): t,�4 Alarm level: 4).4 Alarm in working order(yes or no): Date of last pumping: Air¢ Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not present. DISTRIBUTION BOX: 42(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 4,f Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box has two lattera s No evidence of solids carry over.No evidence of leakage into or out of the box_ PUMP CHAMBER: 40.VC(locate on site plan). Pumps in working order(yes or no): .Ur9 Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.'): Pump chamber .is not present. 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C " SYSTEM INFORMATION(continued) Property Address: 86 Scudder Lane Barnstable,Mass. Owner: Roger Boocock Date of Inspection:1 /15/01 SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan,excavation not required) „ If SAS not located explain why: ` Located Tvpe 7aching pits. number: a w _g2; leaching chambers, number: leaching galleries,number:Q ALQ_ leaching trenches,number, length: C� ,I)o leaching fields, number,dimensions: r? ,t} ) overflow cesspool, number Ale innovative/alternative system Type/name of technology: a�rP Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil;,condition of vegetation, etc.): Loamy sand to ,clay to coarse sand.No signs of hydraulic - failure or ponding.Soils are dry.Vegetation is normal.#1 pit Waste water is 59" below the invert pipe. #2 pit is dry at this time. Both pit covers are to grade with cast iron ring & covers. CESSPOOLS:j2d&,�(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: D Depth—top of liquid to inlet invert: . . Depth of solids layer: �A Depth of scum laver: 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.): cesspools are not present- PRIVY:A&&(locate on site plan) Materials of construction: Dimensions: 1 } Depth of solids: ,�JA Conments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Privy is not, present, y 9 - A h - Page 10 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued).' Property Address: 86 Scudder Lane Barnstable,Mass. ' Owner:Roger Boocock Date of Inspection: 1 /15/01 SKETCH OF SEWAGE DISPOSAL SYSTEM p 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: r bay/ '' a 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: 86 Scudder Lane arns a e,Mass. Owner: Roger Boocock Date of Inspection: 1 15 01 SITE EXAM Slope ' Surface water Check cellar Shallow wells Estimated depth to ground water io = 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) All Checked with local Board of Health-explain: - ,olf —TzChecked with local excavators; installers-(attach documentation) Accessed USGS database-explain: ,Gyi9 You must describe how you established the high ground water elevation: Installed system 6/23/87 No water enr•c)untared at 14 ' Permit # 87-404 On file at the narnstah'Ia Board Of Health . 11 y+•nrnrr--n•rr—.•rr- rnrmr•nmrrnn rerrrerr:•.r-r-e.r.�srernn•rrrrly r.v�r+s+:rs•s .rmrJ-r-r.—.—..-..._...F 1 TOWN OF Barnstable BOARD OF HEALTH SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I r..••T•......—-.t�^.r.-r.m rT•n:+at r•+r wsrr rrr.n'r—•.�*•-ir++*r��rmvr--e�n*av+�r�nnrre+�srt mn t+•nsrrnrs��-r+�.+r.•.:r rr r-•z. ._..A -TYPE OR PRINT CI.EARL1'- PIIOPERTY INSPECTED STREET ADDRESS 86 Scudder Lane Barnstable,Mass. ' ASSESSORS MAP , BLOCK AND PARCEL ' OWNER' s NAME Roger B0000ck PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son InQc - COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State LIp COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 790 ) 1578 rt A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , -accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED r` The inspection which I have conducted has not found any information which indicates that 'the system fails to adequately protect public hea1Lh or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not -evaluated are as stated in the FAILURE CRITERIA -section of this form . System FAILED* The inspection which I have co ticted has found that the system - fails to Protect the .j)ublic health and the environment in accordance with Title 6 , 310 CMR 15 .-303 , and as specifically noted , on PART C - FAILURE CRITERIA of this inspection form . Inspector Si nature ' —/ P S Date ✓� �� ne copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF HEAL'I'll. * If the inspection FAILED, the owner or"'operator shall up grade system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 16 . 305 , partd .doc TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE �"� �',(')�C ASSESSOR'S MAP Cz LOT �S ' ` fi ® INSTALLER S NAME 6z PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) � ✓`1 (size) NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER . l BUILDER OR:OWNER DATE-PtRMIT ISSUED: G '� .DAT D,.COMPLIANCE ISSUED: 'ARIANCE'GRANTED: Yes No m e. s , CA,. r O ASSESSORS MAP NO: f�l ��. PARCEL N0: Fi a.: THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF H,EALPVI -/!°�- �L/ ....OF..... ... App iraa#ion for Dispas al Works Tono rurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys t: �/ - -- ------------- Location-Address or Lot No. •.......... .... ... ........................ .....................•---....................._...... -•-------••-...................._•.... owe Address �,1 ...:........: ---.... ---..........----------- ............ Installer Address UType of Building .� Size Lot............................Sq. feet Dwelling iNo. of Bedrooms......��-•-_-----------_-__---Expansion Attic ( ) Garbage Grinder ( ) ` 1 Other—T e of Building .... No. of persons............................ Showers — Cafeteria a' Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 0� Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-_____-__-_- Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-_____________---_____. 44 Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----......................................................... 0 Description of Soil-•-------------- -•------•-•--•------•----•-------•--------------------------------------------------------------------•---...............- W ---•-------------------------------------------•---•------•-----•----•-•------. ............•-•-----------•-- .- U Nature of Repairs or Alterations—Answer when applicable__.._.__ 7__....._.. 6� �� -------------•----------•----•-•--..---------••--•-------•--•-•-••---•------------....------.--••.--- > Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i i i L L 5 of the State Sanitary Code— The undersi' ed further agrees not to place the system in operation until a Certificate of Compliance has bee ssued by th yoa 1 th. Signed. = ......�- - ---- - - - -------- --------- ----- Application Approved By------------ y `'— Date Application Disapproved for the following reasons----------------•-•-----......--•-----------------------------------------------------------------------•-------- --•-••-----•------•-----------------------------•-•-•--•---•---••••-••-----••-•-•-----••--••--•--•-•---•- Date Permit No----- _�..�... 6-•.------------------------- Issued.................. ................__..__............. Date R -77 THE COMMONWEALTH OF MASSACHUSETTS BOARD p ::. ......OF.../ ...... .............................. Appliratiun for Uiuiruual Works Tonstrurtiun Prrutit Application is hereby made.for a Permit to Const tact ( ) or Repair ( ) an Individual Sewage Disposal Sy at: ....� . ..__ .. ----------------•---- ------ -.-------------------------•.------•----- _ . .. .. '- •.._.....Lo.ation:.Address ._.....----•..............................or Lot No. O Address w --•.................................."---.. Installer Address d Type of Building/ Size Lot............................Sq. feet U Dwelling z< of Bedrooms_._.. -_. -----------------•Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria PI Other fixtures ..............•---------•-----•---•----•---•----•---•-.•---------------------------•-----•--•-•---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—Nlo. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) I Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water-___---.--.------------- G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_____--__-----___. =`1----------------- ODescription of Soil--------------- ....-------•-•------------•----------------------------------------------------•------------------------------------_----- UW --------------------------------------------------------------------------------------------------•---------- • j- Nature of Repairs or Alterations—Answer when applicable-_____`.` ._0® ... ----�.................................... .......................-........................................................................ -- rs Agreement: The undersigned agrees to install the aioredescribed Individual Sewage Disposal System in accordance with the provisions of i 5' of the State Sanitary Code— The undersi ned 'further agrees not to place the system in operation until a Certificate of Compliance has tefissued by t bo o" th. Signed_..... _ .�... s_. _...... .. Date ApplicationApproved By............ y-4 =...."•...`•..."}................................... ....................................•... Date Application Disapproved for the following reasons:-----••-------••-----------------------•---------------•---------------------------------------•---------------- •-•--------------------•----------•---•--•---••------------•.....--------------.......---------........_.._..._._.....---•-•----------------•-----•------------------------------... -------------- Date Permit No..... 1 ....... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALT , ......oF.. .. � Trrfifiratr of Tuntplinnrr Tcr� 1 RTIFY Th t the Individual Sewage Disposal System constructed ( ) or Repairedby------- <...1��- P �,. ............................................................................... Installer has been installed in accordance with the provisions of '11T .E j of e State Sanitary Code as described in the application for Disposal Works Construction Permit No._1?..... A_L/.............. dated----------...................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................6..r...�..�-r --------------------•---- Inspector....._ . . ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEAL H •.....OF.... ...��-C... ............ .. ......................... No......................... FEE ................. btu uu u u dun uan rrntit Permission is herebyant�-_-.)t. � �--� .... . to Con7r_i.�trr ( )ram Repair ( Individyad�ge Dispos stem � �Gat No.. ...... �� .... �� .... ....... Street as shown on the application for Disposal Works Construction Permit No('��7:.��.?�__ Dated.......................................... .............•- - .. `.. ------------------------------ ...--_ Board of FIealth DATE---------••----•----------------------------------•-••-•- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS l- t `° w TOWN OF BARNSTABLE �' I i � Pr Lei S B ` I!OC ATION :�CGtI' _ E�VAGE # ' VILLA f ��` ASSESSOR'S MAP 6z LOT GE��- '�n � �' INSTALLER'S NAME PHONE NO. //�G�� - 0 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 2' ,J (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERC j BUILDER OX OWNER DATE PERMIT ISSUED*-- ,., DATH COUPLIANCE ISSUED: �V.ARIANCE GRANTED: Yes No f� K! s �� i