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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Abbey Gate Rd
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
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.
A. General Information
1. Inspector. 51 tf' q
Frank Nunes III
Name of Inspector .
saa
Company Name
25 Deer Ridge Rd
Company Address
Mashpee MA 02649
City/Town State Zip Code
508.272.6433 130I
Telephone Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2/10/09
lnspector"ignaW Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Abbey Gate Rd
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Pumping suggested every 3 yrs to prolong the life of the system
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
Observation of sewage'backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Abbey Gate Rd
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
City/Town 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:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Abbey Gate Rd
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cunt.):
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 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 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 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Abbey Gate Rd
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ . Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
s 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)]
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Abbey Gate Rd,
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
Citylrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): unk
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: unk
^ Date .
Commercial/Industrial Flow Conditions: ' '
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding.tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Watee meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 54 Abbey Gate Rd
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Appears to have been pumped recently due to
disturbed grass and conditions in tank
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: ' gallons
How was quantity pumped determined?
Reason for pumping:
i
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:
1994 per age of the home
Were sewage odors detected when arriving at the site? ❑ Yes ® No
T
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Abbey Gate Rd
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
24"
Depth below grade:
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1'6"
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: 1000g
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle >12'
Scum thickness 0
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
How were dimensions determined? measured '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Abbey Gate Rd
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert '
Level w/the bottom of the pipe
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 approx. 2' below grade and appears to be in good condition
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 54 Abbey Gate Rd
Property Address
Darras
Owner's Name
Cotuit MA 02635 2/10/09
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:'
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-
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pit is 2' below grade, of standard construction, and is dry at this time
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Abbey Gate Rd
Property Address
Darras
Owners Name
Cotuit MA 02635 2/10/09
C4rrown State Zap Code Date of Inspection
D. System Information (cunt.)
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.
`G
G
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Abbey Gate Rd
Property Address v
Darras
Owner's Name
Cotuit MA 02635 2/10/09
Citylrown 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 groundwater elevation:
. Obtained from system design plans on record .
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain: ,,.
w
❑ Checked with local excavators, installers-(attach documentation)
® Accessed.USGS database-explain:
You must describe how you established the high ground water elevation:
Cape Cod Commission web site
06 0 r
No....- _.. Fxa......A00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
G lAppliration for 1i� uuttl urk� Tomitrnr#iun rami#
[�g�
Applicatio her made for a Permit to Construct (4 or Repair ( ) an Individual Sewage Disposal
System at
•---- ••--�... �� ,j�a.._ --...... --•---•--- --------•--- •----•-------------------- .--- -•----
Location-A ress or Lot No.
.....•....• _ . ......•.. ...............................
....
W 9 Ow ress
Installer
� Address
Type of Building Size Lot
..... ....O._✓�._U..Sq. feet
Dwelling—No. of Bedroom//s''._//___-_--- _________________Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building U"--__ _.. . . ORA-No. of persons____________________________ Showers ( ) — Cafeteria
°"�l - ( )
� Other fixtures ---------------------------------------- ---- //j
W Design Flow....................... Q............gallons per p n per day. Total daily flow-.______-___.�.Z)...................gallons.
WSeptic Tank—Liquid capacity------------gallons Length________________ Width_-------------- Diameter.--------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water_._--..____._-____..__-.
(T4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
t� �
Description of Soil........ _. , _
U •••-•'-••---•-•-----------------•--._.....-------•--•'.....'•'---•-•-•-----•---------•-••----....-•-•--•'--•...---------'------------•'•-•----------•-'-•-••--------•------•----•---•-•-•---•-----••....
&-.X;?
V Nature of Repairs or Alterations—Answer when applicable._.__._ _�_ _� C,.. .._ �....�.. ... .__
........................................A.1,W-:....for.0. 1— A ---...�.. -------......-----------••-•'--------...--•--Agreement: bAt
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Cqqe—The undersigne further agrees not to place the
system in operation until a Certificate of Com II ce has n is by the b health.
g ...... �'
Signed .
Application Approved By ------- -- ------------------ ----------------- ..--------- --— - --------- - .. ... ................... .................................... ..—
Dare
Application Disapproved for the foll..........owing reason : .................................:.................................... . ... ....... ..
-- ---- ------------------------------------------------
----- ..
....... ---------
.,
------------------- ....... .........
... ../�-------
Dace
Permit No. ........ --------- Issued ...........1/.......
Dace
No.._ _.. �) FEB....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di-lipwial nrkii Towitrnr#ion Vrrmit
Application`is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:, �7��". ,,-
...._._ U -----• ----
Location-i�ddress or Lot No.
/��,�, ... 1 r a a J---------------------------------------- sic
--------------------
Ow,ne; j Address
a ---_.... ` --------I ------------------------------------------- ----------=�''---- _ ,.......................................................
Installer Address
Type of Building _ Size Lot..... .._()_.�'_()._Sq. feet
Dwelling— No. of Bedrooms----------- ----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures -----••-•-------------------------------- j-------•-------------------•--------...............-_._.._..------------•--•----•--------•------------.
Design Flow.......................N..t��._.__.__-_--g gallons per person per day. Total daily flow....-..-_._--.3_:_---.. gal
fzl a ions.
WSeptic Tank—Liquid capacity-_-....._-_-gallons Length---------------- Width---------------- Diameter................ Depth................
x Disposal Trench—No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No---------------- -- Diameter-------------._-..-- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY--------------------------- -------•-----•-------------------------------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
fit Test Pit No. 2................minutes per inch Depth of Test Pit_.----___-_-_-___- Depth to ground water........................
Rr'
xDescription of Soil-------- ............. .
V ------------------------------------------------•------------------------------------------------------------------------------------------•---------------------------------- -------------------
W ------•--•-•----------------------------------•--------•----------------------------•------------- ------------ ---
�;
U Nature of Repairs or Alterations—Answer when applicable........ -�. �.. _._ L m /
.- --•---•--- ----..................Al !►�------ - V�� c. .¢ ------f ....
A...--•------------------------------------- --------- .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental C de—The undersigned further agrees not to place the
system in operation until a Certificate of Compr'liance has edn is. e by th �FXIhealth.
Signed ... ........ .........: ..,.... cs-----...
Application Approved BY ��'. %...... ........ ......:........y.. ........�.. .—' / ! . . �(
i /------------`-- ✓ t 'C." -mac: ........................... ----------------Dam.....-----------
Application Disapproved for the following reason : ... ............................................... ...... . .............. .......
------------ -------- ----------------------------
J� I Date
Permit No. .....................:......... ! .......... Issued j _�.._
Date �-�
-----------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certtf rate of CZomplinure
THIS�rIS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V) or Repaired ( )
_/ �by---...� �----- . ....
In^roller +
at .................. ....... /......... ................. '% ....,,�}G%fl.. �i!/.' -
has been installed in accordance with the provisions of TITLE/� of he St to lronmental Code as described in
the application for Disposal Works Construction Permit No. ` ,2_ ....^...'_. . ..... dated .........._.._.........._....._.._.__..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEFAS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. y
��
DATE..._... .� `�-------------------7-------------------------------------- Inspector ... v ---...._-------- ----------------------------------------- ----
---- ---------------------------------------------------------------------- --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
TOWN OF BARNSTABLE °
No�l..-�............. FEE...
v
i ern �t.1_ nrk Ton atrudinIn rani
Permission is hereby granted......��-.J......-� .e ./��t� _ _
to Construct ( y/or-- Repair ( ) an Individual Sewage Disposal System /
at No. a ........ / C .fiJ'—t°. �/I /�t `�' G�__,_ -t `......a ..-
_._... --- -•----•------ ----
Street / Z.ted
as shown on the application for Disposal Works Construction Permit No.-`-_.�_.._.__- _.._.... 7.....
R
--------------------------__ 'T_.�l. -------------------------------------------------------------
l��`e Board of Health
D V
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FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS
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LOCATION
VILLAGE_ COLA ASSESSOR'S MAP & LOT. oOcZ a66
INSTALLER'S NAME & PHONE NO. ��, Sh;Sca1- -771- L 4b
SEPTIC TANK CAPACITY p00 �, cl�a f
LEACHING FACILITY:(type) l_Po�G� Q (size) tjwqoj6,s
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER �� S \ .\�`� Co. —d
T
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED__
VARIANCE GRANTED: Yes No
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SEPTIC TANK CAPACITY
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NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
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4 DATE COMPLIANCE ISSUED! S
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