HomeMy WebLinkAbout0018 WESTCHESTER WAY - Health a
18 Westchester Way
Ba,mstable
. • - 072
Jul 30 2017 2029 HP Fax page 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments •
CID
18 Westchester Way �--
Property Address _j
Karl Geercken
Owner Owner's Name
information is OD
required for every Cummaguid A4 MA 02637 7-28-17
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 A. General Information
filling out forms 67* /a C ```�ulrt+u+lrrarpi
on the computer, ��� jH OF kfq
use only the tab 1. Inspector: � 9c
key to move your ap��dF tiG
cursor-do not ��: JAMES
James D. Sears '•.
use the return E 0 -+
key. Name of Inspector 5v: SEARS y-�_
Capewide Enterprises �
'•.
Company Name •.,RTI '.QQ :
153 Commercial Street �'�o�F s•1NSP�����r
Company Address +rrtmr111
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S 1623
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 16.340 of
Title 5(310 CMR 115.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7-28-17
actor's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Hoard
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 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.
t6m.doc•rev.6r16 Title 6Official Inspection Form.subsurface sewage Disposal solem•Page 1 o117
,�o VS
Jul 30 2017 2029 HP Fax page 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
information is Cumma uid MA 02637 7-28-17
required for every G
page CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E I 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 is a 1500 Gal,Tank D Box and pit.
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):
15lns.clac-rev.5116 TIUe 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 2 of 17
Jul 30 2017 2029 HP Fax page 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner owner's Name
information is required for every Cummaguid MA 02637 7-28-17
page. cityrTown State Zip Code Date of Inspectlan
B. Certification (cost.)
❑.Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpslalarms are repaired.
i
B) System Conditionally Passes(cunt.):
❑ 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
16.303(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
Mns.doc•rev.6/16 Title 6 Official Inspection form:Subsurface Sewage Disposal System•Pepe 3 of 17
Jul 30 2017 2029 HP Fax page 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owners Name
information is required for every Cummaguld MA 02637 7-28-17
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:
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 111IMM" is less than 6" below invert or available volume is less
day flow P than '/Z it
t5ins.doc-rev.6116 Title 5 otf4al inspection Form:Subsurface Sewage Disposal System-Page 4 cf V
Jul 30 2017 2029 HP Fax page 5
Commonwealth of Massachusetts
Title 5 official Inspection Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
requiretlfo Is Cummaquid MA 02637 7-28-17
required 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 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.
i
❑ ® 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 falls. 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.
t5ina.doc-rev.6115 Title 5 Orrwlal Inspection Form:Subsurface Sewage Disposal System•Page 5 of V
L
Jul 30 2017 20:30 HP Fax page 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
information is required for every Cummaquid MA 02637 7-28-17
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 NIA)
® ❑ 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 Soll 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): 3 Number of bedrooms(actual):
3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms). 330
l5ins.dot rev.6l16
Title 5 Officiel Inspection Form:Subsurlace Saga Disposal System•Page 6 of 11
Jul 30 2017 2030 HP Fax page 7
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 18 Westchester Way
Property Address
Karl Geercken
Owner Owners Name
required for every information is Cummaguid MA 02637 7-28-17
require
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal Tank D Box and pit.
0
Number of current residents:
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 years usage(gpd)): 2015-25,000GaIs2016-29,000Gal's
Detail:
Sump pump? ❑ Yes ® No
NA
Last date of occupancy: Date
Commercialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatslpersons/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:
lSins.doc•rev.616 Title 5 Official brsaecuon Form:Subsurface Sewage Disposal System•Page 7 of 17
Jul 30 2017 20:30 HP Fax page 8
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
information is Cummaguid MA 02637 7-28-17
required for every
page. Cityrrown 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: NA
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)
❑ InnovativelAlternative 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 IlA system by system operator under contract
❑ Tight tank. Attach a copy of the D E P approval.
❑ Other(describe):
l5ine.doc-rev.6116 Title 5 official Inspection Form:Slbstlface Sewage Disposal System-Page 8 of 17
Jul 30 2017 20:31 HP Fax page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
information is required for every Cummaguid MA 02637 7-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cone.)
Approximate age of all components, date installed (if known) and source of information:
1986 Permit # 86 - 1038. 7-2017-New D Box-outlet Tee.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
28"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40
Septic Tank(locate on site plan):
16"
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: 1500 Gal. Precast H-10
2"
Sludge depth:
t5lns.doc-rev.6116 Title 5 Offxial Insmebon Form:SuUs rface Sewage Disposal System-Page 9 of 17
Jul 30 2017 20:31 HP Fax page 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
information is MA 02637 7-26-17
required for every Cummaguid
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
1"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 17"
How were dimensions determined? S uilt-Tape-Plan
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 and cover's at 16" below grade. Inlet tee. Outlet tee. No sign of
leakage or over loading
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.6116 Title 6 Official Inspection Form:subsurface Sewage Disposal System•Page 10 of 17
Jul 30 2017 20:31 HP Fax page 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r
18 Westchester Way
Property Address
Karl Geercken
Owner Owners Name
information Is Cummaquid MA 02637 7-28-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
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:
Material of construction:
❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(explain):.
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
•Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ine.ceoo-rev.itis Title 5 Official inspection Form:Subsurface Sewage Disposal System-Pagel 1 of 17
Jul 30 2017 20:32 HP Fax page 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
informationrequired
is Cumma uid MA 02637 7-28-17
required for every q
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 0
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 is 16"xl 6"-4'-7" Below grade Wone line out. D Box is New 7-2017 w/cover at 6".
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.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
tSins.doo-rev.6/18 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Jul 30 2017 20:32 HP Fax page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
w 16 Westchester Way
Property Address
Karl Geercken
Owner Owners Name
information is required for every Cummaguid MA 02637 7-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont,)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overtlow 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.):
Leaching is a 12'x6' H -20 pit w/3' stone. Pit at W below grade w/steel cover on edge of black top
drive. Pit is dry w/no sign of over loading.
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
15ine.doc•rev.6116 Title 5 official Insper ion form:Subsurface Sewage Disposal System-Page 13 or 17
Jul 30 2017 20:32 HP Fax page 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
information is required for every Cummaguid MA 02637 7-28-17
paw. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.).
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6r15 Title 5 Of5ae1 Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Jul 30 2017 20:32 HP Fax page 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
information is required for every Cummaguid MA 02637 7-28-17
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
'SLR e k
3
upPs� � r3
'bFck-
U °
.,= 'V9'
1/✓ ��= 7'
t5lns.doc rev.6/16 Title 501ficial hspelion Form.Subsurface Sewage Disposal System-Page 15 of 1T
Jul 30 2017 20:33 HP Fax page 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
information Is
required for every Cummaguid MA 02637 7-28.17
e
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth t"h ground water: 29
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: 1-19-87
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
U.S.G,S, well AIW.247
You must describe how you established the high ground water elevation:
Test Boring on plan 1-19-87 29' no G.W.. Bottom of pit at 21' below grade. Bottom of pit at 8'
above T.H..
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Wns.doc•rev.9116 Title 5Official lnsMtion Form:Subsurface sewage Disposal System•Page 16 of 17
Jul 30 2017 20:33 HP Fax page 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Westchester Way
Property Address
Karl Geercken
Owner Owner's Name
Information is required for every Cummaguid MA 02637 7-28-17
page. City/Town 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
i
l5ins.doo•rev.6116 Title 5 OPodal Inspection Form:Subsurface Sewage Disposal SyWem•Page 17 of 17
No. d —23 7 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: LZ
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIPPlication for Mioozal *pgtem Cow5truction Permit
Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System IX Individual Components
Location Address or Lot No. I GS-r<-H EA LkAi Owner's Name,Address,and Tel.No. 1
13" 6i<A P I- + A4 0 0164 CVi5C- e-KGj
Assessor's Map/Parcel 3i q J -ILICAAO E �J "h+Lt-, Cr
Installer's Name,Address,and Tel.No. J 08 417-28 77 Designer's Name,Address and Tel.No.
CAPEcvlb c 1G7u-F&2P1.c1SV5 �P t\J/A
Type of Building: �, )
Dwelling No.of Bedrooms 1v Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures / ,
Design Flow(min.required)_/ gpd Design flow provided Nz gpd
—
Plan Date Number of sheets Revision ate
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -:rfjST4 ,, —Goy, LI;j fT
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of He lth.
Signed Date
Application Approved by Date 2
Application Disapproved by: Date
for the following reasons
Permit No. ZO 17 — 2 3 Date Issued
No. d f L J 7 Y �J
Fee
t.'
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
i, PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
T[ppYfcaltion for Digotal 6pztem Conttruction Permit
Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑ Complete System GK Individual Components
Location Address or Lot No. WJ ST�ST�Q = y Owner's Name,Address,and Tel.No.
� .� kARG-t. MoNle,.4 GrCC:XQ-K�.N
Assessor's Map/Parcel �i( b� -
Installer's Name,Address,and Tel.No.J U OC"Y /7 7"'8 2 T7 ' Designer's Name,Address and Tel.No.
Type of Building: A
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) Jy gpd Design flow provided N 1,� gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
i
I , I
Nature of Repairs or Alterations(Answer when applicable) -:r Js i o,� t't"�c) r)-i3Q}( Uj (Ty+ k6-0Z,--
a
Date last inspected:
a Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
x accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date *7-,;l
1
Application Approved by `a Date 2- 2 p — / 7
Application Disapproved by: Date
for the following reasons _
'a. Permit No. G ( 7 - 2 3 Date Issued % - 7
?U j THE COMMONWEALTH OF MASSACHUSETTS
n + BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( A) Upgraded ( )
Abandoned( )by C� w��� Ex-7WAJ567S
at 12 ( 6&7-Ch aS74E . 1AIM 301AW5`rAGQ5 has been construed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. o 1 7 dated '7 Lo -7 .
�- ./,S
Installer �l'�c►�1�� E � C�, Designer MIA
#bedrooms 14- Approved design flow /�/� gpd
The issuance of this permit shall not be construed as a guarantee that the system funcfion`a wtlls designed.
Date 1 k
rt- J /' r Inspector
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
w
Ii.5po!5al 6p.5tem C011.9trUctton Permit
Permission is hereby.granted to Construct ( ) Repair (x ) Upgrade ( ) Abandon ( )
System located at 2 -P,57r¢��.C►
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this peltni .
Date I U b -7 Approved by
U
Commonwealth.of Massachusefts
Title 5 Official lns ec ionf. t orrr,
p
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Westchester Way, Cumm�id
ASSESSORS MAP NO• q GI
Property Address — --� - -- PARCEL N0: —
John Van Iderstine c/o Cathleen McAbee
Owner Owner's Name -- -. - — —
information is 1582 Main Street Route 6A, East Dennis MA" 02641 August 5, 2009
required for every — — ___ g9
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.
Important:When A
fillingout forms A. General Information
on the computer,
use only the tab 1.
key to.move your Inspector: COPY
cursor-do not Troy Williams
use the return key. Name of Inspector
Troy_Williams Septic Inspections
Company Name — - —"- — -— --- -
19 Hummel Drive
Company Address _ -- - — —
South Dennis MA 02666
City/Town State Zip Code -=
508 385-1300 S1682
Telephone Number License Number
z
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 15.000).The system:
Passes ❑` Conditionally Passes ❑ _Fails,
❑ Needs Further Evaluation by the Local Approving Authority
Au ust 5, 2009
—�- --ate
Inspector's Signatute Date _
The system inspector shall submit a copy of this inspection report to the Approving Auth—Mity (Bard
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 s6; Yrtit tfie
report to the appropriate regional office of the DER. The original should be sent to the Vem Bruner
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.
18 Westchester Way,Cummaquid 03/08 Title 5 Official InspedionFdrm:Subsurface Sewage Disposal System Page 1 of 15
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Westchester Way, Cummaquid_
Property Address
John Van Iderstine c/o Cathleen McAbee
Owner Owner's Name --
information is 1582 Main Street, Route 6A, East Dennis MA 02641 August 5, 2009
required for every _ _ —_ Dennis— 9 _
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cost.)
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 Mass DEP at the time of inspection only. This inspection.is
not a guarantee or warranty on the future working conditions of leaching, pipes or components. _
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair_, as approved by
the Board of Health, will pass.
Answer yes, no or not determined(Y, N, ND) in the❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced,with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
N/A -- —
ElObservation 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 ,
18 Westchester Way,Barnstable•03I08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,.M 18 Westchester Way, Cummaguid__
Property Address -- -- --- — — ---
John Van Iderstine c/o Cathleen McAbee _
Owner Owner's Name
information is 1582 Main Street, Route 6A, East Dennis MA 02641 August 5, 2009
required for every
---- --�-
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) ---
B) System Conditionally Passes (cont.):
❑ distribution.box is leveled or replaced .
ND Explain:
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
❑ obstruction is removed
ND Explain:
N/A I
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or.the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland,or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has 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.
18 Westchester Way,Barnstable•03108 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y(o 18 Westchester Way, Cumma uid
Property Address — -
John Van Iderstine c/o Cathleen McAbee _
Owner Owner's Name
information is required for every 1582 Main Street, Route 6A, East Dennis MA 02641 August 5, 2009
- -. - - - _
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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: N/A
*" This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to oI
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
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
18 Westchester Way,Barnstable-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Westchester Way, Cummaa uid
Property Address
John Van Iderstine c/o Cathleen_McAbee
Owner Owner's Name
information is 1582 Main Street, Route 6A, East Dennis MA 02641 August 5, 2009
required for every g
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 1..00 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 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 Zonell 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.
18 Westchester Way,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Westchester Way, Cummaquid
Property Address
John Van Iderstine c/o Cathleen McAbee
Owner Owner's Name
information is 1582 Main Street, Route 6A, East Dennis MA 02641 August 5, 2009
required for every _ g
page. City/Town State Zip Code Date of Inspection
C. Checklist
a
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)]
18 Westchester Way,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Westchester Way Cummaquid
Property Address
John Van Iderstine c/o Cathleen McAbee__
Owner Owner's Name
information is required for every —`�
1582 Main Street, Route 6A, East Dennis MA 02641 Au ust 5, 2009
- - -
page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3- Number of bedrooms(actual): 3 .
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Number of current residents: 0
Does residence have a garbage grinder? Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last'2 ears usage d 08=80,000gals
g ( Y 9 (gpd)): 07=150,000gals
Sump pump? ❑ Yes ® No
Last date of occupancy: Vacant approx. 1
_year_
Commercial/Industrial Flow Conditions:
Type of Establishment:. N/A
Design flow(based on 310 CMR 15.203): N/A
Gauons per day(gpd)
Basis of design flow(seats/persons/sq, ., etc.): N/A
ft
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
Last date of occupancy/use: . N/A
Date
Other(describe): N/A _
18 Westchester Way,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 15
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
nM 18 Westchester Way, Cummaquid
Property Address
John Van Iderstine c/o Cathleen McAbee
Owner Owner's Name
information is required for every 1582 Main Street, Route 6A, East Dennis MA 02641 August 5, 2009
_ �_
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: No urnping info was available.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A `
Reason for pumping: N/A ----- ---
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):
Approximate age of all components, date installed (if known) and source.of information.
.Tank,d-box& leaching,were installed on 5/12/87peercompliance: "
Were sewage odors detected when arriving at the site? ❑ Yes ® No
18 Westchester Way,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 18 Westchester Way_Cummaquid
Property Address
P Y
John Van Iderstine c/o Cathleen McAbee_
Owner Owner's Name
information is required for every —1582 Main Street, Route 6A, East Dennis MA 02641 Au ust 5__2009
_
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cony.)
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 with good flow through to leach pit.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: N/A .
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
----------------------------------------------------------- ---------------------------------—-------------------------
Dimensions: 6'X 10.5' X 6' _ 1500 gallon
Sludge depth: --
2'6"
Distance from top of sludge to bottom of outlet tee or baffle. — -
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 _
18 Westchester Way,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Forte
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!" a 18 Westchester Way, Cummaa uid
Property Address
John Van Iderstine c/o Cathleen McAbee _
Owner — — "
Owner's Name
information is 1582 Main Street, Route 6A; East Dennis MA 02641 a August 5, 2009
required for every _-_ — _ _�u_ _
page- Cityrrown 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.):
Pvc inlet and concrete outlet tee's were present. 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 Q metal D 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
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):
Depth below grade: N/A.
r
Material of construction:
❑ concrete F1 metal ❑ fiberglass '❑ polyethylene El other,(explain):
N/A
18 Westchester Way,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Westchester Way, Cummaquid
Property Address
John Van Iderstine c/o Cathleen McAbee
Owner Owner's Name
information is required for every 1582 Main Street, Route 6A, East Dennis MA 02641 August 5, 2009
---- - --- --- --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions: N/A
Capacity: N/A _
gallons
N/A
Design Flow:
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Level with
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 in working order with good flow through to leaching.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
18 Westchester Way,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 15
Commonwealth of Massachusetts
s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Westchester Way, Cummaquid
Property Address -- -
John Van Iderstine c/o Cathleen McAbee
Owner -- ---
Owner's Name 7
-
information is 1582 Main Street, Route 6A, East Dennis MA 02641 Au ust 5, 2009
required for every _ _g
page. City1rown State Zip Code Date of Inspection
D. System Information (cone) -
Comments(note.condition of pump chamber,condition of pumps and appurtenances; etc.):
a
N/A
Soil Absorption System (SAS)(locate on site plan, excavation not required):"
If SAS not located, explain why` r
N/A
Type:
leaching pits number. , 1-12'x6'pit
w//3'stone
❑ leaching chambers number. ,. _H_20grade.
❑ leaching galleries ' Y number:
❑ leaching trenches , numberjength': ----
El leaching fields number, dimensions.` _-- — --
overflow cesspool number. --
❑ innovative/alternative system . w
Type/name of technology: — - - —
Comments(note condition of soil, signs of hydraulic failure, level.of ponding, damp soil, condition of
vegetation, etc.):
Soil was sandy and rocky. Leach pit`was found dry on inspection with no evidence of hydraulic failure
or problems in the past found at the time of:,inssection. Steel cover to grade.
18 Westchester Way,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Westchester Way, Cummaquid
Property Address
John Van Iderstine c/o Cathleen McAbee
Owner Owner's Name
information is 1582 Main Street, Route 6A, East Dennis MA 02641 August 5, 2009
required for every _ 9
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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
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 solidsN/A'
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
18 Westchester Way,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,N 18 Westchester Wes, Cummaquid
Property Address
John Van Iderstine c/o Cathleen McAbee
Owner Owner's Name — — -
information is 1582 Main Street, Route 6A, East Dennis MA_ .02641 August 5, 2009
required for every _ — — _g—
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building. `� 1
I
l•
i
l
&G(AL 6 1
2
W�
Iy,3'1 C. 2 , � r
2-7
(5 2=
18 Westchester Way,Barnstable•03108 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Q Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
" 18 Westchester Way, Cummaa uid
Property Address
John Van Iderstine c/o Cathleen McAbee _
Owner Owner's Name -----
information is required for every 1582 Main Street, Route 6A, East Dennis MA _02641 August 5� 2009
__-- �
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: 40+ ---
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
plan `
If checked, date of designlan reviewed: 7/30/86-
Date.
® Observed site.(abutting property/observation hole witKin 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database -explain:
AIW 247 Zone C 23.1' 3.2',adjustment
You must describe how you established the high ground water elevation:
USGS groundwater map for Barnstable showed groundwater to be approx. 707. Groundwater
adjustment in area at the time of inspection was 3.2'. Bottom of leaching at 21.5'was found not to be
located in the high groundwater elevation at the time of inspection with a minimum separation of
49.2'. Test hole on plan also showed no water found.__
18 Westchester Way,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 15 of 15
TOWN OF BARNS T ABLE
LOCATION /X-CZ S T C E s T E'!l w.�y .::SEWAGE
VILLAGE v �L� ASSESSOR'S MAP LOT
INSTALLER'S NAME & PHONE NO.AZG H
SEPTIC TANK CAPACITY 5- 00
LEACHING FACILITY:(type) Zif pe1w %iis (size
NO. OF BEDROOMS PRIVATE WELL ORCBLIC WATER
,
BUILDER p. R �i u
DATE PERMIT ISSUED: 1012 w�
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
t
Dr
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S
a 17,
ASSESSORS MAM'O.
No...S6..... ...... q3e FX
- I
.............................. .�
im �? G
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF....1�4Y.A.S+jt.6
34q-07b .. ...............................
Alipfiration for Dispaiial Morkii-gowitrurfivit Prrmit
Application is hereby made for a Permit to Construct ( �)_or Repair an Individual Sewage Disposal
System at:
&
0
.. ... .... ......... ----4-t ....
d Loiapion-Addjess
45 — x. 4
-r 68;1 ........�.,O,_C(..
....jKK.&A........................... ... -S-4-
.
...................................... ......... ......W.................................................
.............................. ...
Installer Address L.L1
U Type of Building Size ....Sq. feet
.3
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
a
Other—Type of Building ..,;................ No. of persons............................ Showers CafeteriaOther es -----------------
-----------------------------*'-"*-------------------------------------------4....4r................
Design Flow...........*M1 gallons per person per day. Total daily flow............... .........................gaUons.
1:4 Septic Tank—Liquid capacity)j2W..gallons Length___.
....... Width__.(......___ Diameter.-44........... Depth..ZaAkl*
Disposal Trench—No..................... W14th.................... Total Length..................._ Total leaching area-- sq. ft.
Seepage Pit No..................... Diameter.V..:k_1---- Depth below inlet.............._..._ Total leaching area.i
Z Other Distribution box ( ) Dosing tank ( ) -2
Percolation Test Result Performed by......151_61�� ......... Date...........
$..4 "1 'lip-------------
Test Pit No. I minutes per inch Depth of Test Pit..___Z*_LC Depth to ground water-.-"- -+t4Xj%4Cf
44 Test Pit No. 2..... .._....minutes per inch Depth of Test Pit-----147L719.7 Depth to ground water.___-____.__...._...
P4 ...........
0 .........* . .....Z . . .......... .... . ......... .... .........
Description of Soil .....0......... ---- .1 1 .. . &;�i
-- - ---------
U ............................................. ....... ........11�0..... .......4S.'rA."Ja......�/..!�.�
W
........................................................................................................................................................................................ ...............
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 TT 5 of the State Sanitary ode e undersigned further agrees not to place the system in
,L-. "N
operation until a Certificate of Complia �n iss d h and of health.
7 1012,leg
..... ...... .............................. ..........................
ApplicationApjfr*oveBy� ........................... .... ........ ............................................ ........................................
Date
Application Disapproved for the followin r asons:..............................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... IssuedL.......................................................
Date
1 � _
No........................ Fps..........................
THE COMMONWEALTH OF MASSACHUSETTS
_. -.. BOARD OF HEALTH
44`` J
....................�..................OF.....1 7...........
Applirutiun for Disposal Works Tuntxnr#ion rrmff
Application is hereby made for a Permit to Construct () ) or Repair ( ) an Individual Sewage Disposal
System at:
f t �j �_ j} t r _� r � r
�..r � 1 <I () 6* 1 aJ� 1�' k,°a`fi"t c GQ A._. ....ix) .... ......� n /� ...._ •{.�T.�`6o:----1 'ra ..__ r. ,a r:�.�,
..................... ....._...... ........._................_...... .. .._
1 Location-Address or Lot No.
Lj
c
Own ier `` � 'Address
W 1� ...... L i..J1� .
Installer 9 Address / ���
Q Type of Building Size Lot__ .j._.___.___._•-.-•Sq. feet
U 13
Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder (11�
Other—Type of Building No. of persons............................ Showers ( ) — Cafeteria ( )
QOther fix res ......-.�'. ---------•--------•-........................----...............................................................................--------
Desi n Flow..........:. .. .• 3�allons per person per day. Total daily flow__.__- =
W g .,�..�---...._..-----•----g P P P Y• Y �-��--�--------•-• ---•--•-----gallons.
WSeptic Tank—Liquid capacit,�_St.-.V'..gallons Length...!_1........ Width._........... Diameter______________• Depth..l_.'-_r'-_6.'
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter_('.)... .... Depth below inlet.................... Total leaching areaEr�lt. _....sq_it. C t�l`
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by....... ..._.. ,^,i,. .. ............................. Date._. =_----._••�._ -_!._--•--.
Test Pit No. 1_.t,�___------minutes per inch Depth of Test Pit....!.` ._r_''Depth to ground water..,......
!�
f r - Pc_ 7- L�i, 6!Lj'� ,
44 Test Pit No. 2-----9)........minutes per inch Depth of Test Pit....,�.���_v._:. Depth to ground water.__-._..._. .......
D Description of Soil...--- " ...)4_r...... .r.r e- S �- , s c 1_ ,
x � ; � U y�
U ------------------------- - ,
Wyr r ..r t�_x--L:(� �.v j
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i T t'TTLE of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Complianc -b en issued by th/e.,.board of health. /
Date
Application Ap rove -••-••......-•-••-......... •- .�- l o - ? b
} ....................Date......------
Application Disapproved for the followihg easons:
-----------------------------------•------•--------...---•------------------------........--•-------...----•-----------.......--••-•----••------••-------------•----•--...---------------------•--------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!.. .�`�. ...................oF... G..✓... ..5.. .� -*.............................
Trrtif irtttr of f�omplianrr
T 1,y IS TO C RTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( }
by...... � ) C` ...... A ...............................................................
...... ----------�--------------/---------------------------------------------------
aller
at QC3�C'. Vw "J' .. ; �G- '� �--.---- ......-•-------------•--... --- ------ i ---- .---------------------------
has been installed in accordance with the provisions of TILT E 5 of Tu State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------- -- �__�................. dated___..-_---_.-.--_---_-_-_---_--__--_-_-____---
THE ISSUANCE OF THIS CERTIFICATE SHALe �NOT�BE dbNSTRUE® AS A GUARANTE TI•IAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................... ....... ................... Inspector.-•-- ...... -_---------•---••-----
41— 0 7� THE COMMONWEALTH OF MASSACHUSETTS
-_. BOARD F HEALTH
........r0W.Y1.............OF.......... QC_�!�,�. .....................
No.J _;v�. FEE......
... ............
wiuposal Works Tontr ion "rani#
Permission is hereby granted..............................................................................................................................................
to Constr ct (✓) or Repair S_ _) an,Individu Se�rage Disposal Sy tem
atNo..1_4...�el.�etfr.eG145 _W_a ...... -- -•--i....lQd...•....................................................
J Street
as shown lication for Disposal Works Construction ermit No..................... Dated..........................................
..........................•
DATE - . 44 ad � uor `
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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