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Home My WebLink About0156 TONELA LANE - Health 156 TONELA LANE - Barnstable A= 336 -032 D Pef f i Commonwealth of Massachusetts 334a- &&,-L, Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ ND �u 156 Tonela Lane W Property Address Ellin Gallagher +-- Owner Owner's Name T information is required for every Cummaguid MA 02630 6-18-19 ; 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. r1cZr. Important:When p �/ filling out forms A. Inspector Information t3 02 on the computer, I O y use only the tab James D.Sears JAM key to move your Name of Inspector 3 EARS y cursor-do notuse Capewide Enterprises key. return Company Name 5y' RTIF\'�.-*0 153Commercial Street yF s I N Sp�G�.��`� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes . 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6-18-19 ector'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 f c Commonwealth of Massachusetts Title 5 Official Inspection Form .iQ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 156 Tonela Lane Property Address Ellin Gallagher Owner Owner's Name information is required for every Cummaguid_ MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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 is a 1000 Gal. Tank and Pit. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tonela Lane Property Address Ellin Gallagher Owner Owner's Name information is required for every Cummaquid MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 0 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): i ❑ 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): 3) 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. . a. 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: t5insp.doc"rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form lll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tonela Lane I-V Property Address Ellin Gallagher Owner Owner's Name information is Cummaquid MA 02630 6-18-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. C. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tonela Lane Property Address Ellin Gallagher Owner Owner's Name information is required for every Cummaquid MA 02630 6-18-19 page. City/Town State. Zip Code Date of Inspection C. Inspection Summary (cont.) f 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded 01/� El El Static clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than '/2 day flow Piz" ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 4 ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tonela Lane Property Address Ellin Gallagher Owner Owner's Name information is required for every Cummaquid MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: 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 Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] I j . t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tonela Lane Property Address Ellin Gallagher Owner Owner's Name information is required for every Cummaguid MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information , 1. Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal. Tank and pit. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 2017-46,000GaIs g ( y g (gp ))' 2018-56,000GaI's Detail Sump pump? ❑ 'Yes ® No Present Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form ^I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tone la Lane Property Address Ellin Gallagher l Owner ,Owner's Name information is required for every Cummaquid MA 02630 6-18-19 , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) } i 2. 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 trapp resent?, ❑ Yes ElNo Water treatment unit present? ❑ 'fifes ❑ No If yes, discharges to:' Industrial waste holding tank present? ❑ ',Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ 'Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): r . I 3. Pumping Records: NA Source of information: Was system pumped as part of the inspection? El Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Paged 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 156 Tonela Lane Property Address y Ellin Gallagher Owner Owner's Name information is Cumma uid MA 02630 6-18-19 required for every q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, 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): Approximate age of all components, date installed (if known)and source of information: 1980 Permit # 129 -80. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 11 feet 33 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.): Pipeing is 4" PVC SCH -40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I'o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tonela Lane ' Property Address Ellin Gallagher Owner Owner's Name ' information is required for every Cummaquid MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information' (cont.) ' 6. Septic Tank(locate on site plan): 23" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" . II Scum thickness 0,l Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 23" below grade w/both covers at grade. Inlet tee w/outlet baffle. No sign of leak age or over loading. f 1. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form In' lI,i� <� Subsurface Sewage Disposal System Form Not for Voluntary Assessments .............. ,, �%F 156 Tonela Lane V� Property Address Ellin Gallagher Owner Owner's Name information is required for every Cummaquid MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass El 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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): 0 Dimensions: Capacity: gallons Design Flow: gallons per day v t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Forma .p� s ubsurface Sewage Disposal System Form Not for Voluntary Assessments emu- 156 Tonela Lane Property Address Ellin Gallagher Owner Owner's Name information is required for every Cummaquid MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date 6 Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Box 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tonela Lane s Property Address Ellin Gallagher Owner Owner's Name information is Cummaquid MA 02630 6-18-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. } 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: j Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tonela Lane . Property Address , Ellin Gallagher Owner Owner's Name ' information is required for every Cummaquid MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 4' precast pit.Pit at 13'-6" below grade w/cover at 13".- 6"water in pit w/no sign of over loading. 12. 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 constructionA Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs_ of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Tonela Lane Property Address Ellin Gallagher Owner Owners Name information is Cummaguid MA 02630 6-18-19 required for every page. City/Town State Zip Code 9 p Date of Inspection D. System Information,(cont.) , 13. 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.): - } . 4 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form `I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Tonela Lane ; Property Address Ellin Gallagher Owner Owner's Name information is required for every Cummaguid MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ; 14. 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 * i 30 9 EAR r n 0-3 @ 3 38' r t51nsp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Tonela Lane `ram Property Address Ellin Gallagher Owner Owner's Name information is required for every Cummaguid MA 02630 6-18-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells F ' x Estimated depth to high ground water: 21 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: Date a ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: local Checked with I l excavators installers - attach documentation ® Accessed USGS database-explain: AIW 247 at 21. . I You must describe how you established the high ground water elevation: USGS well AIW -247 at-21. Bottom of pit at 17'- below grade. Bottom of pit at 4'above TH Depth. t Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 ` h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments /'- 156 Tonela Lane tV� Property Address Ellin Gallagher Owner Owner's Name requir on is required MA 02630 6-18-19 requiredd for every page. City/Town State Zip Code Date.of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed'as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included W,fLL i "1 ieoTfti /7-- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ASC m LOCATION SEWAGE PERMIT NO. VJ...� IAGE F IN LLER'S NAME i ADDRESS 200SPICA-D 3 U I L D E R OR OWN EiiR(( �r'�►2NS r�A'fJ �ld i2S DATE PERMIT ISSUED PC a DAT E C0MIPLIANCE ISSUED r f/o us E 1 T. THE.COMMONWEALTH OF MASSACHUSETTS NOISSUMV403 BOARD OF HEALTHJ01,'_V1W=SN'03 31SY ° TOWN BAR. N.STABLE. f!dV 01 133r ZM ... . -... O F......... .......................... Appliration for BiipnoFal 01irkg Towitrurtion Frrutit is hereby made for a Permit to Construct r 'r Applicationy C st ct ( ) o Repair ( ) an Individual Sewage Disposal System at: Tonela Lane - Cummaquid Lot 14 ................_--....__....................................••---•-----------................. .....-------••-•------•------------•-----------....................--------------................. Location-Address or Lot No. Charles E. McDermott _ __ Rte,.6A - Box 458 - W. Barnstable,... . .......... •--- --.........••----------................. Owner Address W Paul Bousfield Main Street - East Sandwich MA -2537 ....... ..........- r Installer Address 1 4 8 Acre "To of S% Q Type of Building Size Lot...-__'................... fleet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Vo) 'k Other—Type of Building ......... No. of persons............................ Showers Pa YP g ------------------- P ( ) — Cafeteria ( ) Other fixtures -------------------- - W Design Flow---------------14 0..,.---.......-----gallons pe aerr per day. Total dail y flow......- .�5�_---------------...-----O)ons. Al Sep is T nk— �i ui ca acity11 00..gallons L.ngth--------V.. Width............. Diameter................ Depth....It,_--__-- W 1 po�r'Jic� '�..I........ Width......1�...... Total Length........�------. Total leaching area........ZA ..sq. ft. x Seepage Pit No------------------- iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosi tank; ) ~' Percolation Test Results Performed by n.--sK'!1-.`4j' ...b L!?.�_^_ ._.�...;Depth .............. Date... �.r.. ...�� ...... Test Pit No. ..... .Z__minutes per inch Depth of Pit _. ...'' Depth to ground w ter...... E._. i ri, Test Pit No.3...G ..minutes per inch Depth of Test Pitg4t. . .._-.0 to ground water...... voN "- P4 •----•••-••••------•--•-----••-•--••--••....._-•-..•- ------------- 0 Des grip 'on of Soil..........See -percolation test report Ze.�/ - - - ------ ........ - � •-------•�--------�-��-"---L-Oe��±�►�__.�.r__/Z-----,�sr�SarL.�_/Z-'-go----.S��eny_.�an-�-�'"-��---�-�°'-��-zLarTi/l U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ---------------------------------------------••--•-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersig ed further agrees not to place the system in operation until a Certificate of Compliance has en issued by the bo rd f h lth. A/ ' ' w — Y Signed-----�!�'....--•--•---•---------- ------- ----------------------- ---- -- .......................... a Application Approved By....l „tl�f �..,/� / /�9. ................ Date Application Disapproved for the following reasons:............................................................................................................... Date Permit No......................................................... Issued-.-- f ° - Date /02 Fps.. ... ... No....d'�........../�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF.....----- BARNSTABLE Applira#ion for Disposal 10ox s Tomarnrtinn ramit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: Tonela Lane - Cummaquid - Lot 14 •---......--•---................................................................................. .......=.......................................................................................... Charles E. 9664imoit Rte:6A - Box 459 ,ttt *. Barnstable, MA02668 -••...................-•--- -- - --- ........... .................................................................................................. w Paul Bousfield owner Main Street - Easte"Sandwich, MA -2537 Installer Address 1 4 8 .� op"'! Q Type of Building Size Lot_........................... aThree Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder VO) PL4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QI Other fixtures w Design Flow...............).q ...._ ..gallons per�pereson per day. Total daily flow._._... Via........................onl1pris. G� Sep c Tank /(Liqujd:c pacit�Q� ..gallons ngth___.._ ..... Width...�......._ Diameter -__--_--_-_- De th� _._..... Disposal TrNnch—No. .._.... '.......... Width-•-•-_1_..____-_-- Total Length.......° ____. Total leaching area.....................sq. ft. Seepage Pit No...................... iameter---------------- Depth below inlet....................Total leaching area..................sq. ft. Other Distribution box (t Dos i tank ) z Percolation Test Results Performed b �' °' N°r"� Date.. .. j �g Test Pit No l'_ _"`` '°_..minutes per inch Depth of Test Pit`..` _. . Depth to ground w ter------ "'-p`_ Test Pit No ..'� °...minutes per inch Depth of Test Pi%�'�� .:.'.` Depth to ground water.__. ``�'�' p Sed peraolatildn,. test repoit De rI ion of Soil j g s / j}^ /� / ✓ f G�4.thY f x '63 t 2 $a4� I -• l..d -••.•. ! w e '^ `F f✓ep >f i {F ¢ f t d ! r p� tm t tFr y' f yy t U Nature of Repairs or Alterations-Answer when applicable..........:................................................................................ ..__. -------------=------------------•--•----------------------••------------------------................----..•...--------------------------------•-••. ......--•-•-••-•-•••------........................ Agreement The undersigned agrees to install the aforedescribed Individual'Sewage Disposal System in accordance with the provisions of iITT,;.. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.................... ---------_..._ ate Application Approved By ,ac 'r..,, ' � �. Date Application Disapproved for the f ollate ing reasons:--....-----------------=----------•----•------------••-----------------------•--------------•-••--......-•-. ...........................................••-••••••---••--•--•--•••-•••-----••.................•--••••---•---•-----•--•-•-•---•••----••-•••---••-•--•--------•--•------•----•••----••......---•------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ...................OF....0.4�i ..�.tr. ........................................ wrtifiratr of Tomplianrr THIS I CERTI , Th the dividual Sewage Disposal System constructed ( or Repaired ( ) •-----. --------------•---------------- ----•---•---•-•-•-•-•----•-------•--------------------------------- by------------- .. Q Installer has been installed in accordance with the provisions of TIT LR �L � ate Sanitary Code as described in the application for Disposal Works Construction Permit No..9 _-A dated: ...._.-...................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED IS A G ARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. p � 1 DATE..----•-7-.: .�..0 -------------•--..........-----.......... Inspector. .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................®F....- ,M ...-------------•--...------.............. •� ..'...� No .............. FEE✓.:...........--•--- t L Permissiohereby granted -•-- --•-- --------•-------•---------------------------•--•----...........---•----- to Construct ( ) or Repair ) an Indivi al Sewa=�4� atNo...... *, " ......... 0-1K&4 .....:� c---.....-- -•-•------------•-------------------------------------------------••- PP P � • �_�/ _ as shown on the application for Disposal Works Construction P it No __- ____. Dated-----------------•-...................._. ....... -•-- -- 7 Board of Healt DATE....... % v..............•••---......------......---- FORM 1255 HOBBS & WARREN. INC.. 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