HomeMy WebLinkAbout0110 SPYGLASS HILL ROAD - Health 110 Spyglass Hill Road
Barnstable
A = 353 —001 006
Commonwealth of-Massach Usetts 00
Title: 5: Official•, Ins-pection Form,,--
Subsurface
-_ Sewage Disposal System Form Not for Voluntary Assessments
1
o
4
1108pyglasshiI rd
Property Address
Jim McGarry a
Owner Owner's Name "` __.
information is
required for.every Cummaquid Ma 02637 11/27/15
page: City/Town. , ; `-'"' State Zip Code' ""Date of lnspectioh -
;_.:
Inspection results must be submitted on this form. Inspection forms may*hot be alterdO in any
way. Please see completeness checklist at the end of the form.
Important:When A. General:l.nforrnation
filling out forms -- -2 -on the computer, <
use only the tab 1 Inspector:
key to move your
cursor-do not Michael DiBuono
use the return
<%_Name of•Inspector
key. < ;
DiBuono Sewer and Drain
raa Company•Name
.8 Johns path
Company Address
� S Yarmouth MA ;, t.02664
City/Town -_ - _ _ State 1 i t T`'' ; Zip Code
508,-364-9587 S113522
Telephone Number- License Number
B. Certification
i, `� ::i •` Wr` .Ft � c., ..�.,'-.°:: ,� : 6f• ;:ri ,il;u.,� t'% �.. t;;tl; '1 v .1r'i...,:?!.. jL�:, f ��E"'ti- t � t`i 1. f. ; ��•'r,,
±_ l certify thatl,have personaally inspected thd:sewage'disposal fsystem-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"ba`sed-on my training and experience in the proper function and maintenance of on site..
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation b he Local Approving Authority
11/30/15
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.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Dispos S stem•Page 1 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
information is required for every Cummaguid Ma 02637 _11/27/15
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:
The system contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles
are in.place. The Distribution box is level and at normal level. The leaching is made up of a single
leach pit. Level in pit was 28 inches below invert at time of inspection.
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 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
2
}
Commonwealth of Massachusetts
'W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
information is Cumma uid Ma 02637 11/27/15
required for every q
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 1
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
�.' 41
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e' 110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
required for
is every
Cumma uid
required for eve q Ma 02637 11/27/15
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.
z;.❑ 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:
a ** 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:
,Yes No
E ® 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspections Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
information is Cummaquid Ma 02637 11/27/15
regoired for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ -Any portion of the SAS, cesspool orrprivy,is beloW liigh 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.
14 ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
y ❑ ® 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 yvith 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.
i 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
Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection
El
Area—IWPA) or a mapped Zonq II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not'for Voluntary Assessments
110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
information is
required for every Cummaguid Ma 02637 11/27/15
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
❑ 0- 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 us two week period?
P P
❑ ® 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
.t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
information is
required for every Cummaquid Ma 02637 11/27/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles
are in place. The Distribution box is level and at normal level. The leaching is made up of a single
leach pit. Level in pit was 28 inches below invert at time of inspection.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
.,. Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
:f information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
X Water meter readings, if available last 2 ears usage d 219 GPD
9 , ( Y 9 (gp ))�
Detail:
B ,
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
yhi r.
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'°t 110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
information is
required for every Cummaquid Ma 02637 11/27/15
page. City/Town 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: Unknown
r
Was system pumped as part of the inspection? ❑ Yes E. No
If yes, volume pumped: gallons
r 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. w-
❑ Other(describe): .
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
information is q required for every Cumma uid. Ma 02687 11/27/15
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
25 years
v Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
=. Depth below grade: 28"feet
Material of construction:
cast iron ®40 PVC ❑ other(explain):
s Distance from private water supply well or suction line: feet
F Comments (on condition of joints, venting, evidence of leakage, etc.):
System is vented throught the roof.
y .s•
Septic Tank(locate on site plan):
Depth below grade: 2 ft
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gallon
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:
l5ins•3/13 Title 5 Official Inspection,Form:Subsurface Sewage Disposal System•Page 9 of 17
Commoinwealth of Massachusetts
W 'Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,Mb 110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
information is every Cumma uid
required for eve q Ma 02637 11/27/15
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
24"
3"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick
>How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
::•� liquid levels as related to outlet invert, evidence of leakage, etc.):
No evidence of Ieaking,Tees and or baffles in place at time of inspection.
v }.
Grease Trap(locate on site plan):
Depth below grader NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: —
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3m Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 or 17
Commonwealth of Massachusetts
v Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owners Name
information is
required for every Cummaquid Ma 02637 11/27/15
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.):
Tees are in place and levels are normal.
=,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.):
I
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M •'°° 110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owners Name
information is
required for every Cummaquid Ma 02637 11/27/15
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 At normal level
i 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 is level and at normal level with no signs of carry over or decay.
a'
i' Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
0. Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
t
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 112 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owners Name
information is Cumma uid Ma . 02637 11/27/15
required for every q
page. City(Town State Zip Code Date of Inspection
D. System Information (cont.)
Type.
® leaching pits number: 1
0 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.):
No signs of carry over and no signs of hydraulic failure
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page•13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owners Name
information is
required for every Cummaguid Ma 02637 11/27/15
page. CitylTown 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.):
No signs of ponding or hydraulic failure.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owner's Name
information is required for every Cumma guid
Ma 02637 11/27/1.5
page. City/Town State Zip Code Date of Inspection
D. System Information (cont:)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate °
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
._r
I�
V
r
s
j
t5ins•3/13 Title 5 Official Inspection Form:Subsurface'Sewage Disposal System•Page 15 of 17
Commonwealth of 'Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owners Name
information is Cumma Uid
required for every q Ma 02637 11/27/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Site Exam:
® Check Slope
® Surface water
❑ Check cellar
m❑ Shallow wells
Estimated depth to high ground water: 10 + ft
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 2/6/1990
Date
(' ❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
n ❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test hole data on plan dated 2/6/1990 indictaes NGE at 156"
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
i
Commonwealth of Massachusetts
• Title 5 Official Inspection F®rm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
110 Spyglasshill rd
Property Address
Jim McGarry
Owner Owners Name
information is
required for every Cummaguid Ma 02637 11/27/15
page. Cityfrown 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
r• f
Z- 0T /O TOWN OF BARNSTABLE
LOCATION //0 SEWAGE # 6?0- I l "
VILLAGE ASSESSOR'S MAP Sk LOTj_is�-�6
INSTALLER'S NAME & PHONE NO. 8I6-Z; ee7l-7
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS y PRIVATE WELL O UBLIC WATER
BUILDE$.AR OWNER Ly79,fJ
DATE PERMIT ISSUED:_ j -16 ' 9e
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes
d
17"
2�
y d
i
bb�
NO.. V r FxB.. .........._`-
THE COMMONWEALTH OF MASSACHUSETTS
�i BOAR® OF HEALTH
. TOWN OF BARNSTABLE
Appliration for Disposal Works nfitrurtiatt ranfit
Application is hereby made for a Permit to Construct ( " or Repair ( ) an Individual Sewage Disposal
System at:
Lo on A ess j or Lot No.
-- .. ...�. _.. ..... ---------- ••.......
7-----------------------•-•-•••----------------------._...................
...._....._
Own r Address s
W
Installer Address
Type of Building Size Lot...�,�... . ...Sq. feet
aDwelling—No. of Bedrooms...___.___..........................Expansion Attic ( ) Garbage Grinder ( )
p-, Other—Type of Building ............................ No. of persons..........._................ Showers ( ) — Cafeteria ( )
04 Other fixt res .......................
W Design Flow_.__._._..>`�__.......____________ ____gallons per person peer days Total daily flow.....................P6
....................
R: Septic Tank—Liquid capacity g g p f®�.gallons Len tb1O_ . Width..^_&_. Diameter______.:........ De th.l-_�.^-..C�..
Disposal Trench—No..................... Width...... Length.................... area...................sq.No.... Depth below inlet....... Total leaching area//.
Z Other Distribution box Dosing tank
'-' Percolation Test Results Performed by..kA:—'_<— _ ......... Date....L..l.Z'.._.I®..:....
Test Pit No. l.r^<.Z_minutes per inch Depth of Test Pit__/4��...... Depth to ground water_ '.-
(_, Test Pit No. 22�.:grtminutesper inch Depth of Test Pit. .___. Depth to ground water._ "ft
x ........................................-.................................................................................=................................0
Descriptionof Soil--------- -----. ------=_��____?.'�.__�-- --------------------•-•------------..._.--•-•-•--•---•--------•
x
w .
UNature of Repairs or Alterations—Answer when applicable.......................................................................................0....__.
--------•---------------------------------------------------------•------------•-•--•----..........---•-•----••-••--•-----•--------------•----------•---------•----..........................•.........
Agreement: s'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal:System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Co liance has iss by the board of health.
Signed7n .-
..... ------------------...... . ..--....:...--------...... .... `... .. ---- --�. toApplication Approved BY.. ... ... . ... . ............. �. . ... ..--------....i.---------- ----- �.toApplication Disapproved for the following re
.... ✓- .................................................................X.....ti..................................te-----------.......
.................................. ... .......... ------...........
I?a....................
Permit No ....................... ued ..----
.
Noi r�.T..�....
4
y THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diopooal orko C� strnrtion ramit
R' Application is hereby made for a Permit to Construct ( V or Repair ( ) an Individual Sewage Disposal
System at:
yJLo/cation A/ddress �/' /� 7 - or Lot No.__.._____. ..............
i
+ Owner Address
Instal I er Address Q
dType of Building Size Lot... Z .e�__Sq. feet
_U p Dwelling=No. of Bedrooms.....___.:.__________________________m.Expansion"Attic ( ) Garbage G/nder, ( )
`4 Other—Type of Building No. of persons____________________________ Showers — Cafeteria
Other fixtures --------------------------• ..........................
Design Flow...... .................gallons per person per day. Total daily flow.........................._®..... .............gallons.
WSeptic Tank—Liquid capacity e gallons Length/O.ne 4_ Diameter________________ Depth.4^__.C;!,
x Disposal Trench—No..................... Width-----_.............. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..... -------- Diameter./.n`_.___. Depth below inlet......,...".___ Total leaching area. 9-R.Qgsft:
sa Z Other Distribution box ( /—)--- Dosing tank ( ) f /' /
'-' Percolation Test Results Performed by. Gam ?" • 'I` __.
--- - �' Date '.... �--------
aTest Pit No. L-t�7" =.minutes per inch Depth of Test Pit.-..�-� ..__._ Depth to ground water_�� '
Test Pit No. 2.."S_"2 minutes per inch Depth of Test Depth to ground water.. ? !`.
ODescription of Soil........... .........�- = ------... % n ------------••---•------------------------------------------
x
-•------•-••---•--••••-•-•-....•••••-•-•-•-•-•-•-•--•-•••-•--••-•••.....-••••••-•-••---••••----------••••••-•--•••••-•••-••••---•-•••••-•-•-----•••..................................•-•••••--•••--••---
w
VNature of Repairs or Alterations—Answer when applicable................................................................................................
. ---••-•-•-•-......---•••-••---•--...-•••----•--•----••-•••-----•--•••--••--•-••-•••------•••----•---•--••-•--•--=---------------•-••......•-•-....--•..................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Com, liance has��+issu d by the board of health.
�G Signed-
.F ..• o- "` '-:` %r
Application Approved By .-/-/---: :- �7- .....
� ... .. . ..-1..
�� jV � a �t��
Application Disapproved for the following rear ny- .................................-----------------------------------------------------------------------------------------------------
--
>�re
Permit ... �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
r� C rrtifirate of QTpontylinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by................................................... ..................................................................................... ..........................................,.... ........
` Inst Ilex //,/ J
has beenll dl�-- _ .. ��� .f .. !� .-.. .0�� `�'..�.1 ..�------ ------- ----------------
_....
accordance in
with the provisions of TITL 5 f The State Environmental Code as d scribed in
the application for Disposal Works Construction Permit No. ...7�----_ .....-.- dated .�2 rr ..q .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................... ��.." ---� Q
�- - Inspector .......... - ...........:......................................... ........
THE COMMONWEALTH OF MASSACHUSETTS
/ BOARD OF HEALTH
-�� TOWN OF BARNSTABLE
No._...�............. FEE....... ..
Dispooat Works Tonotrnrtion "permit
Permission is hereby granted..............................................................................................................................................
to Construct ) or Repair ( an Individual Se 'age Disposal System14
at
.
F...........
Street
� q q�
as shown on the application for Disposal Works Construction Permit No l_� Dated-----�/�0.--;,, ......
........................... •-• ' ••. ......................................................
DATE......... t2 �`� Board of Health
................................••••••-•-......
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
'►�P of Fo1,�r� i FsZcN1
144-0 14.Z�
O
i
i
NOTE:
-- — — — — — — e>< 7L/r747 ground Pi-ofi/e „ C , ExTC-A.10 ALL F�PPLICR BLE
-o—o-o—o— Proposed round rof'i/e
T O �I VC- RT. ScF�L� : I " /O' MANHOLE COVE)2S TO IA.//TH/Aj
9
F L o b-J -
Cr►-min. %4"p6-r FLOW
ScHEn. ¢o f.a v c. o,e Crninimurr7 Ya,, Per f'oof) /e/Peeas-tone
EQU,.9L To SEPT,c pipe_ -ro BE
7 ?Alk-•
-� --�3•Mr�l• 1',O --1AJj LEVEL FOR-
IT 14-
E"
L QUID
1 1 LEVEL D/5T 8 oX ,
,t.S S�G I_.A� �}I✓L R0,4p !"sump - 3 4 -/ z
Washed�sto e Z E
1 ; 1500 GAL. SEPTIC ToQ"/Z
�X - � D 7-F� / L S
LEACH PlT
0LL- LOG
TF: 7 i2-Rn TES7r' BY= I�1Fs! ass<xa� S
El J, -\
78.o
Ai N WITNESS: E 21' ^ ^iSro� _ 4Eo'_I ���r, t" r ✓�_
L ow RATE- _ GALS.IDAY 1 � l Z
\ 7L3x3 a !�` �®y� 1✓ �. \o S E P r/c 7f9 Nk . f o x /.5= 6,6 b GAF
. p` _� � ,s,/� Ps��'-. /� Fl•,�� � 4 uSE•: 15oc.� GAL. Tf��J� Lo�.t✓1 L_vANi
i 1<cPon�.oJ I2 ,+4Z
E F1 C H l 1V G t9 2 E/q : ��t✓ 73.o sum l L-- �„
74-1-9
! - , I / /J I S/DEGJfiL[ : }F _,S = 47I 3 G.P.D.
0 a
7-07'/9L G.P.D. SaJD
a ,
� USE
f/
Lo
cE�2T/FY THAT THE BU/LD//`../G
�c P�20POSED ON 7 -4E GeoUlv0 AS Iv
SHOWN/ ON THIS PLjgA-1 DOES
a � cO,vFO,eM TO THE 8UILDlw6 sET- — S l TE - S EWIq G E PLFq l\1
�P� �4� s���>✓ Bf-�C IG i2E G?U/�2EMEll.ITs OF THE
TOlnl/lJ OFfi3L-' FOR : LoT 1O S�(G � 1�1LL.RDAD GI-1t�iN14c��1��,1vJ�..
Fl�-� i�ok . Pace
of-
f ai of
Pi2EPARED F02:
ar�P ass
.x E{C'ZTT lY. o ERETT HI SCALE: AS NOTED DgTE:
lifl'1f�{jfY _ 13230
17
"' CIVIL
PLA /v (scF�[ E. ! = �o ) V� E w ,��� ���T.a �F ,U __:, �y ��N1 ML�Q� ,� ��� �► �TS
AYE '�'>'.:-- .;:� ►..---
O. 00 e xisf1nc/ eleVa.-f-�on BL DG. 5ETBF�CK
O.00 = pr-oposed c lee vat/or7 i2EG?U/i2EMElVTS : ;{�pp,QOVED :
- -- - - - - ex/5-f-in c/ confour-s S/ ale t - -7, S BC?1geD OF HEALTH
Conf-our-S � 5 �� Mf�Ss.� -7/4 MA/N STREET
rear YP,2MOUTH PO)2T, MF35S .
P�oFE55lONAL ENG/NEEI25 F` !_ACID SU2VEYo,25 �}`- �
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