HomeMy WebLinkAbout0018 ASH CIRCLE - Health 18 Ash Circle
Cotuit
A = 040 - 078 - - - - -- -- - - - -
f
l
n` eb 23 1511:16p p.1
�. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
irttorrnation is
required for every Cotuit MA 02635 2-23-15
page. Cltyrrawn 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 fllling out forms A. General Information
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1 Company Name
153 Commercial Street �ipl$ rNs4E�������
Company Address
Mashpee MA 02649
CRylTown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below Is true,accurate and complete as of the time of the Inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
L] Needs Further Evaluation by the Local Approving Authority
2-23-15
/nspector's Signature Date.
The system inspector shall su`imit a copy of this inspection report to the Approving Authority(Board
of.Health or DEP)within 30 d2.ls 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.
his 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.
ter,sns
Tide 5 Orlldel dspaalon Form:Substsreoe Se.rage Dlspossd SystefT•PHgB 1 of 17
Feb 23 1511:17p p•2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Ash Circle
Property Address
The Estate of William Ferguson '
Owner Owners Name
informrequired for
is Cotuit MA 02635 - 2-23-15
required for every
page. City/Town 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:
The system is a 1000 Gal.tank D Box and pit.
B► System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need lobe
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 extiiftration 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):
ISlm•W13 Title 5 Offidel Inspection Fomx Subsurface Sewege Disposal System•Page 2 of 17
Feb 23 1511:17p p 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
Informrequired
is Cotuit MA 02635 2-23-15
required for every
page. cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational.System will pass with Board of Health approval if
ppmps/alarms are repaired.
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
15.303(1)(b)that the system Is not functioning in a manner which will protect public health,
` safety and the environment:
I
❑ 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
L51ns 3113 TPoe 5 of del bnspedlon FmTrr SubsuAace Sewage 01sp=1 System•Page 3 of 17
Feb 231511:17p p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
information is required for every Cotuit MA 02635 2-23-15
page, CItylTown State Zip Code Date of Inspecion
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
Ej ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in a is less than 6"below invert or available volume is less
than'/z day flow P.T
t5ins-3/13 Tice 8 OfGdal Irspedon FomeSubsurface Sewage Disposal System-Page 4 of 17
Feb 23 1511:18p p.5
Commonwealth of Massachusetts
Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
Information is required for every COttllt MA 02635 2-23-15
page. City/Town state Zip Code Date of Inspection
B. Certification (cunt.)
i
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s).Number of times pumped:
® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet.
from a private water supply well with no acceptable water quality analysis.[This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303.therefore the system,fails. The
system owner should contact the Board of Health to detemtine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no'to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system.is within 200 feet of a tributary to a surface drinking water supply
Ej ❑ 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.
t5tm•3113 Me 5 Official h spedlon Forth:Subsurlace Sewage Disposal System•Page 5 of 17
Feb 23 1511:18p p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
Informrequired
is Cotuit MA 02635 2-23-15
required for every
page. CIVITown state Zip Code Date of Inspection
C. Checklist
_ 1
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)
0 ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of breakout?
® ❑ Were all system components, excluding the SAS,located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NA Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•3113 Title 5 Mdal Inspection Fwm Subsurfaoe Sewage Disposal System.Pega 6 o 1T
Feb 23 1511:18p p,7
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
requiredfo Is Cotuit. MA 02635 2-23-15
requ[red for every
page. cityrrown state Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal, Tank D Box and pit.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.) -
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2D13-14,000Gals
9 ( Y 9 (gpd)) 2014-9,000 Gars
Detail:
Sump pump? .' {] Yes ® No
Last date of occupancy; NA
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/personslsq.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:
15ins-3l13 Title 5 Offidal Inspection For Subsurface Sewage olsposal System•Page 7 of 17
Feb 23 1511:19p p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
information is Cotuit MA 02635 2-23-15
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: _ i 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: t
® 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 VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
a
t51ns-3J13 - Title 6 official Inspactlon Form:Subsurface Sewage Disposal System•Page 8 of 17
Feb 23 1511:19p p.g
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7
18 Ash Circle
Property Address
The Estate of William Ferguson "
Owner Owner's Name
information Is required for every Cotult ti MA 02635 2-23-15
C' /Town State Zip Code Date of Inspection
page. ItY P P�
D. System Information (cunt.)
Approximate age of all components,date installed(if known)and source of information:
1982 Permit # 82-715. 2015 New D Box. New line into and out of D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'lash
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):
14,.
Depth below grade: feet
Material of construction:
®concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain)
If tank is metal, list age: years
MIs age confirmed by a Certificate of Compliance? (attach'a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal. Precast H-10
Sludge depth:
t5lns•3l13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 9 of 17
r ,
Feb 23 1511;19p 0.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owners Name
iequir a is Cotuit MA 02635 2-23-15
require for for every
page. City/rown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29"
0"
Scum thickness
Distance from top of scum to top of outlet tee or baffle 14"
Distance from bottom of scum to bottom of outlet tee or baffle 16"
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 14r below grade. Inlet baffle,outlet Tee. No sign of leakage or
over loading.
J
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
tSns-3113 Title 5 Oftal Inspecdon Fem[Subvx1aw smaos Disposal system•Pape 1 o or 17
i
Feb 23 1511:20p p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
Information is required for every Cotuit MA 02635 2-23-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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):
s
Dimensions:
Capacity:
gallons
Design Row: gallons per day
Alarm present: ❑ Yes ❑ No
•
Alarm level: Alarm In working order. ❑ Yes ❑ No
Date of last pumping: oats
Comments (condition of alarm and float switches,etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
mns•W13 Title 5 owdel Inspection Form:Subsurrace Sewage t)]sposal System-Page 11 of 17
r
Feb 23 1511:20p p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
information is required for every Cotuit MA 02635 2-23-15
page_ Cttyrrown 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"x21"-T Below grade w/one line out.Cover at 6"below grade Box is new 2-2015..
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:
f5lm•3113 Title 5 Official Inspection Form:Subsurface Se"age Dispose[System•Page 12 of 17
Feb 23 1511:20p p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
information is
required for every cotuit MA 02635 2-23-15
page Cityrrown 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.
❑ 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.):
Leaching is a 1000 Gal. Precast pit. Pit and cover at 2'below grade.Pit is dry. Pit Holes and
stone, looks good. No sign of over loading or solid carry over.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
indication of groundwater inflow ❑ Yes ❑ No
t5ins-3113 Title 5 011dat Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Feb 23 1511:21 p p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson _
Owner Owners Name
information Cotuit MA _ 02635 2-23-15
required for every
page. Cityrrown state Zp Code -bate-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.):
,r
L
t5ins•3113 Title Official Inspection Form Subsurface Sewage Disposal System—Page 14 of 17
Feb 23 1511:21 p p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
Information is
required for every Cotuit MA 02635 2-23-15
e
page. atyfrown State Zip Code Date of InspecBon
D. System Information (cunt.)
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
13
i
14-3 = JL -3
!3- 3_ '
o '
1
15ins-3r13 rifle 5 Official Inspection Form:Subsudate Sewage Disposal System.Page 15 of 17
Feb 23 1511:21 p p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
required o r e Cotuit MA 02635 2-23-15
required For every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cost.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells L
Estimated depth t high ground water, 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
❑ Observed site(abutting propertylobservation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
USGS WELL SDW 253 at 50'+.
You must describe how you established the high ground water elevation:
USGS WELL SDW 253 at 50'+ . Bottom of pit at 8'below grade.
i
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•3M3 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System-Page IS OW
Feb 23 151.1:22p p.17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
18 Ash Circle
Property Address
The Estate of William Ferguson
Owner Owner's Name
information is Cotuit MA 02635 2-23-15
required for every
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
t
r
l51ns•3113 Tide 5 Official Inspection Fonrr.Subsurface Serfage Disposal System•Pape 17 of 17
No. Fee}7'�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for Bisposal 6pstem Construction j3ermit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System X Individual Components
Location Address or Lot No. g A5H C(R,(,(- 4 (oTU I-r" Owner's Nalne,Address,and Tel.No.
kC uroj V. WlLL-1444 Vep-60SOM
Assessor's Map/Parcel a 40 ® Moss A 44c.9 m4asmos K f
Installer's Name,Address,and Tel.No.5'08-477—88'77 Designer's Name,Address,and Tel.No.
l'3 N
Type of Building:
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) A* gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �5P( C ipI m_ Fa4Z x� _6-9Tt L _T7WV,
-TZ D-rbQK 106TWuL ija3 IA-do -130,-4 ua�� �&Zo�, -0-I3ov-
Tim
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 Health.
Si Date t ' f"W5
Application Approved by Date M
Application Disapproved Date
for the following reasons
Permit No. j ®( Date Issued j�ZjT?tZ�
No. //�/ '�� FeA
1
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
-' PUBLIC HEALTH DIVISION - TOWN,,O.FBARNSTABLE, MASSACHUSETTS Yes
2pplitation for i o aY tern Construction r� 8 8 � 8 �0 8 P YTtIt
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System X Individual Components
Location Address or Lot No. g ASH C 1W_jj-_- 4'GFT U t T Owner's Natne,Address,and Tel.No.
n kEUt w fey W I(d.1 h k4 VL'K60SOtM
Assessor's Map/Parcel b 4C) O 1S MO S P 44ci dot�4 rJ5 wt!
Installer's Name,Address;and Tel.No.50 8-477—8fS1717 Designer's Name,Address,and Tel.No.
153 w f4
Type of Building:
t Z
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) /1//Q- gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ��(JQgai—: w N& F-acxm_ st-P7(L
TD ��►3Ok � /N 5�4c:L ly� N a y n I3�A�'Q u4E� use� -Fly u� D-I3 a1C
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
-b Compliance has been issued by this Board of Health.
Si Date clots
i
Application Approved by Date
>- Application Disapproved Date
for the following reasons
Permit No. j— ((� Date Issued //Z/ ��)14
- - -
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THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�) Upgraded( )
Abandoned( )byP�_lc�t��
at ( 9. A&1W C I zcl_ <±o-ru!'I has been c
onstructed,in acco
with the provisions of Title 5 and the for Disposal System Construction Permit J�-y�dt�d
Installer CAP&C-N OE Designer WA
#bedrooms Approved design owflow'
/�' gpd
d tf' �•
The issuance of this permit shall not be construed as guarantee that the system will ctii as desY}'gn d.
Date ( / Inspector
a
No. O' � D � Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
MispoSal 6pstrm Construction 31ermit -
Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( )
System located at t 5? As�4 cl (P—d-L-r C n v r -7-
I
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit
y Date ( gyp Lh Approved b _
li�` CATtO C� C SEWAGE PERMIT p0. ®
'VI
LLAGE
-ru i �-
INSTA LLER'S NAME i ADDRESS
a ht9V4 &d
GUILDER OR OWNER
DATE PERMIT ISSUED Z �73
DATE COMPLIAKCE I S S U E a ,�
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