HomeMy WebLinkAbout0022 BAY ROAD - Health 22 BAY ROAD
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10/I Commonwealth of Massachusetts
F Title 5 Official Inspection Form
`11e Subsurface Sewage Disposal System Form Not for Voluntary Assessments
22 Bay Road
Property AddressA
Joan Lynch
Owner Owner's Nam 4
information is required for every COtuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
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Important:When ,.. •.,
filing out forms A. Inspector Information ' a • ••••
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on the computer, =�: DAMES u'
use only the tab James D.Sears =�:
key to move your Name of Inspector
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P.O.Box 784 �rrrrnnumtfna00
Company Address
West Yarmouth MA 02673
City/Town State Zip Code
508-364-4398 S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
c� 4-27-19
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal. Tank D Box and three chamber's.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
I 4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
--- Title 5 Official Inspection Form
/a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 Bay Road
V�
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in casopmal is less than 6" below invert or available volume is less
than '/z day flow A U01w G
❑ ® 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 water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) (310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1a1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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
Description:
1000 Gal. Tank D'Box and three chamber's.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2017-97,000Gals
g ( y g (gp ))' 2018-87,000Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
e lip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e
;V 22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
�V
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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:
1995 Permit # 95- 1005.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 34"
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.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
0
u 22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
1"
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? 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 2' below grade w/both covers at 6".No sign of leakage or over
loading' Note Tank inlet cover under deck w/removeableboard's.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
u� Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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"x 16"-40" below grade w/one line out. Box is clean and solid w/one line out. No sign of
over loading or solid carry over.
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
u Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
' li; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is three infiltrators. Bottom of chambers at 3'-6" below grade. Camera out,chamber's are
clean w/no sign of over loading or solid carry over.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
22 Bay Road
�V
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
`J Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
C,IC
0 v
i'�t u nrf
I
I
RPY r �
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
T Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
u Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N°
Estimated depth to high ground water: 1 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: pate
® 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:
You must describe how you established the high ground water elevation:
Abutting property and rear of lot drops off 12'+. Bottom of chambers at 3'-6" below grade.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
L'Ni..p.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Bay Road
Property Address
Joan Lynch
Owner Owner's Name
information is required for every Cotuit MA 02635 4-27-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
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RoVom
C141,)IK S. 8�6
l5insp.doc-rev.7/26/2018 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System-Page 18 of 18
TOWN OF BARNSTABLE
LOCATION e`� 9, SEWAGE
�
VILLAGE Cora r ASSESSOR'S MAP&LOT.&W-40 Z
�3 e fi
INSTALLER'S NAME&PHONE NO. Jr, - Al C C�N1 � S 0A/ f
SEPTIC TANK CAPACITY A O D 5 t
LEACHING FACILITY: (type) Z'19 Fi/1rRgWe zS (size) 3
NO.OF BEDROOMS ] _
—844199�OR OWNER
f PERMTTDATE: -z�COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and.Bottom.of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within.300 feet of leaching facility) ® Feet
Furnished by
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36 Y�
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OHO oo�
No..---=s✓..:..:........��� 0..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Apphrativaa for Diipuual Wark.6 Tomitrurtiura hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.2J2...Bay--RsQad...Cotuih_............................................ --•------------------------------•------------•--•--.............................................
Location-Address or Lot No. i
EaaAice..-Wesh-------------------•---••-----------------------------------•---- ------•----------------------------------- --......-•----••-------.....-----.....---------
Owner Address
a .I..-P._Macnmhez 5r--►----------------------------------------------------- ---------------.-.-...-----------------------••---------------------------------•-•--•------------
Installer Address
UType of Building Size Lot............................Sq. feet
Dwellings No. of Bedrooms---------3------------------------------._Expansion Attic ( ) Garbage Grinder ( )
`4 Othemit Type of Building ............................ No. of persons Showers
a YP g P "1---------------- ( ) — Cafeteria ( )
a' Other fixtures -----------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................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........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........---------.-.....
( Test Pit No. 2................minutes per inch Depth of Test Pit.-.----------------. Depth to ground water.....................--.
a .......----•------------------------------------------------------------------------•--•---•-------...---------------------------------••-•--------.....----
0 Description of Soil----------- ----------------------------------------------------------------------------------------------------------------------------•---------------.....-----------
v .................. arid----------------------------------------------------------------------------------------------------------........-------------------------------------------•--------....--
W
x --------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable----Omit---c.esspao_1 _Inat.a1.1...d3 b x.-.t'o....
--------•-------exis_ting---tank...an_Q1 4 z ._t.ratoxs-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Complian e� be issued by e b and of health.
Signed --- ------ ° ----- -------------------- --....................................... .3/2.719.5.......:......
..- c 7.D.Tre
APPhcation.Approved BY .... ----- .. - - -------- --- ------------------------------ ----------✓....:.-- �
�
Date
Application Disapproved for the following reasons- ---------------------------------------------------- -------------------------------------------------------------------------------
....... ............... .._..........
4 �
Permit No. �J `7 .�............... Issued ....._�........................................................
Dace
��... G� � S 30.00
No. . Ftzs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
TOWN OF BARNSTABLE
Appliru'liun for winpuiittl Works (funitrnr#iun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.2.2...3R.rAv_.Road._CcXtit -i-• ........................................----- -------------------------•--.--..-------•----
Location-Address or Lot No.
T?iinl,fMA._fin i -•--•--•------------------------------------- ............................................... -----•-
.. -'------------•-------
Owner Address
..................................................... •-•------•-------------•......................... ------•-
LS.a....e_..-.-..
� Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling);a,No. of Bedrooms---------3--------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOtherrim.Type of Building ____________________________ No. of persons-________1---------------- Showers ( ) — Cafeteria
d Other fixtures ------------------------- ----------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacitv............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 ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit-------------------- Depth to ground water_..-_._._____-_______._.
44 Test Pit No. 2................minutes per inch Depth of Test Pit_______.-.__-.._-_ Depth to ground water.....................
--------------- --------------•--------------------------------------------------------•-----•--••--........--------•-••••••----••-•••--•.........-----------
0 Description of Soil.......................................................................................................................................................................
W .................. and--••-----------------------------------------........................................................
W
------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------••------
U Nature of Repairs or Alterations—Answer when applicable...Omt-._Ceslaoo •-- tt� •..c7�hx-•-Ica•-_
exiatina tank and 4 infiltrators.
-----•---------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance�haa's been issued by the band of health.
Signed ..... ..._`/ .f ,/ - h --- e --3 J 2 7/9 5
..
Application,Approved B -- `' e �"-
PP PP y ---------- --------- __:. . r'11...... ............----------------------- ....� rz_.... .�,j
Application Disapproved for the following reafonf- ------------------- ------i- ----------------` -----L---------------------- ----------------- .... ........
-----.......................................-................................................---- ----------------------------------'-------"----...-------'--------'--------------------..... -----------------
Due
Permit No. ---- "'.. � 2 Issued .._. �. .� `.
F -------- T �.._.....
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�ertifirate of C11umplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX`)
by ---------- a.T.....P..MarOMhe-r..---jr."...... ...... ....L...... ..L................... ................. _.._------._._--------------------------- -------------------------------------
Imuller
at ..............22Bay RoadCotu t -- --------- -----.. --------------- - --- --------------------- ----- ---------------------------
- .... . ..._..
PP PConstruction
p State Environmental Code as described in
01
the application tionlforlD Disposal
alaWorkstConstru t onI PermitTI 5 of The datedrE
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU0 AS A GUARANTEE THAT T
SYSTEM WILL FUNCTION r_'TISF7A0'Y—.
41
DATE -----f. ..--- ------------------- Ins ctor... / --------- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C� TOWN OF BARNSTABLE
No..!. FEE... a_-
�iu�ru�tt1 Turku �unu#r�t.c#iun �rrmi#
Permission is hereby granted J..P.•Macomber... r ---•---------------------------------•-------------•----•-•-••-••••.......---......
to Construct ( ) or Repair ({X;) an Individual Sewage Disposal System
at No.._..22...Bay. Road Cotuit
--•-•••-
Street �-
as shown on the application for Disposal Works Construction Per •t :��_'_-/ '3D tteedd`_._ _.". .• ��
Board of Health
DATE.............�•-F---••............... .........................
FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS
DATE: 5/31/02 ----
PROPERTY ADDRESS: 22 Bay Road
-----------------------
Cotuit ,Mass .------------------------
02635------------------------
On the above date, I Inspected the septic system at the abrve ci�dr b7s.This system consists of the following:
1 . 1-1000 gallon septic tank . JUN 0 4 20022 . 1—Distribution box . WN OFBARNSTABLE
3 . 3-infiltraors in. series . HEALTHUEPT.
Based on my Inspection, I certify the following conditions:
. Y 9
4 . This is a Title five septic system. ( 78 Code . )
5 . The septic system is in proper working order
at the present time . D`�� '
6 . System installed . 3/30/95 Permit #95/1005 MAP
PARCEL ' ®�
LOT
SIGNATURE:_j, _
Name :_ �_�,_ Macomber �J_rJ_ ____
Company: Joseph_P _ Macomber—& Son , . Inc ,
Address : Box 66
Centerville , Ma . 02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
• i i
JOSEPH P. MACOMBER & SON, INC,
Tanks-Cess pool s•LeachIIeIds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632.0066
775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
r CERTIFICATION
Property Address: 22 Bay Road
Cotuit ,Mass .
Owner's Name: John Jansen
Owner's Address: Same
Date of Inspection: 0
Name of Inspector: (please print) Joseph P.Macomber Jr .
Company Name: J.P .Macomber & Son Inc .
Mailing Address:Box 66 Centerville ,Mass . 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
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:
'r&Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: �- 1�•�
The system inspector shal bmit 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.
Notes and Comments
***-*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. /
Title 5 Inspection Form 6/15/2000 page 1
I
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 22 Bay Road -
Cotuit ,Mass .
Owner: John Jansen
Date of Inspection: 5/31 /0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A =sumases.
h;ve;n;ot;f;6u;nd;an;, nformation hich indicates that any of the failure criteria described in 310 CMR
15:303 or 4 exi exist. Any failure criteria not evaluated are indicated below.
Comments:
The sentir system is in orooer working order
At the nrecent time
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.
IVQ 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:
A_ Observation of sewage backup or break out or high static water level in the distribution box due to brokemor
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
distribution box is leveled or replaced
ND explain:
i ``U� 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:
2
I
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 22 Bay Road
otuit , ass .
Owner: John Jansen
Date of Inspection: 5/31/0 2
C. Further Evaluation is Required by the Board of Health:
4/0 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:
Va Cesspool or privy is within 50 feet of a surface water
Z4� 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:.
NO 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.
,ovo The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple.
40 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
aThe system has a septic tank and SAS and the SAS is less than 1020 e t but 5 feet or more from a
private water supple\�,ell". Method used to determine distance ,�t
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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:
F
3
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Add ress:22 Bay Road
Cotuit ,Mass .
Owner: John Jansen
Date of Inspection: 51 1 1 /fl2
D. System Failure Criteria applicable to all systems:
You must indicate 'yes" or"no" to each of the following for all inspections:
Yes No
, ackup 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
V_sL. quid depth in,�Kp�l is less than 6"below invert or available volume is less than ''A day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
/oftimes pumped 6).
�y portion of the SAS, cesspool or privy is below high gr6und'water elevation.
—
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
yT"
yYater supply.
_ portion of a cesspool or privy is within a Zone I of a public well.
portion of a cesspool or privy is within 50 feet of a private water supply well.
portion of a cesspool or privy is less than 100 feet but greater than 50 feet.from a private water
supply well wish no acceptable water quality analysis. 1Tbis system passes tl the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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,j
k (Ycs'No) The system fails. I have determined that one or more of the above failure criteria exist as
drscribed in 310 CMR 15.303. therefore the system fails. The system owner should contact the Boare e'
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 now of 10,000 gpd to 15,000
gpd
You must indicate either'yes" or"no" to each of the following:
(7he following criteria apply to large systems in addition to the criteria above)
yes no
_ he system is within 400 feet of a surface drinking water supply
_ v th system is within 200 feet of a tributary to a surface drinking water supply
/i the system is located in a nitrogen sensitive area Interim Wellhead Protection Area — IWPA or a mapped
_ Y 8 (_ ) PP
Zone 11 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
"\es" in Section D above the large system has failed. The owner or operator of any large system considered a
s!emFicant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10,CMR
304 The system owner should contact the appropriate regional ofrice of the Department.
4
Page 5 of I l
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 22 Bay Road
Cotuit , Mass .
Owner: John Jansen
Date of Inspection: 5/31/0 2 '
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 ?. r
Were all system components;�luding 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:
Yes o
— 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(3)(b)]
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 22 Bay Road
Cotuit ,Mass .
Owner: John Jansen
Date of Inspection: 5/31 /0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):
Number of current residents: /I
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage systems or no): _ [if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no):_AI'6 `
Water meter readings, if available(last 2 years usage(gpd)): 7— 01/o'
e r •Sump pump(yes o no). Al
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 316 CMR 15.203):. gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):M
Industrial waste holding tank present(yes or no): "�
Non-sanitary waste discharged to the Title 5 system (yes or no):k�-
Water meter readings, if available:
Last date of occupancy/use: �U19
OTHER(describe): VA
GENERAL INFORMATION
Pumping Records
Source of information: �(�`�LCi
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped: _gallons -- How was quantity pumped determined? 4(
Reason for pumping: ZZ4
STYP OF SYSTEM
eptic tank,distribution box, soil absorption system
A)� 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)
Tight tank /4 Attach a copy of the DEP approval
�a Other(describe):
Approximate ase of qll ompo nts,do to 'nstalled (if known nd source of information: "
i
Were sewage odors detected when arriving at the site(yes or no):e)
6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 22 Bay Road
Cotuit ,Mass .
Owner: John Jansen
Date of Inspection: 5/31 /0 2
BUILDING SEWER(locate on site plan). b
Depth below grade:
a
Materials of construction: _cast iron 140 PVC 44 other(explain):,
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.): .
Joints appear tight . No evidence of leakage .
SEPTIC TANK: locate on site plan) lax���•L�Cw�
Depth below grade:
Material of constructincrete.f1d metal 1fiberglass�polyethylene
N�dotlper(explain) on: co
If Lank is metal list age:Xle) Is age confirmed by a Certificate of Compliance(yes or no):.40(attach a copy of
certificate)
Dimensions:
Sludge depth: T r a c e
Distance from top of sludge to bottom of outlet tee or baffle: trace
Scum thickness: Trace
Distance from top of scum to top of outlet tee or baffle: T r a c e
Distance from bottom of scum to bottom of outlet tee or baffle:T r a c e
How were dimensions determined: Measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.): ,.,
Pump septic tank every 2-3 year.s . Inlet & outlet tees, are in
place .The tank is structurally sound and shows no evidence
of leakage . Liquid level at the outlet invert is 51"
GREASE TRAP (locate on site plan)
Depth below grade:AM
Material of construction:,l concrete,&metal k fiberglass�_�olyethylene,L other
(explain):_ 164
Dimensions:
Scum thickness: leol
Distance from top of scum to top of outlet tee or baffle:��
Distance from bottom of scum o bottom of outlet tee or baffle: 14# —
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Grease trap is not present
f
7
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 22 Bay Road
Cotuit ,Mass .
Owner:John Jansen
Date of Inspection: 5/31 /0 2
TIGHT or HOLDING TANK4�,a(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: AM
Material of construction: concrete AIAmetal,fiberglass Aft9 polyethylene�f other(explain):
Dimensions: -
Capacity: gallons
Desien Flow: a gallons/day
Alarm present(yes or no):
Alarm level: AR Alarm in working order(yes or no):
Date of last pumping: zo
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present
DISTRIBUTION BOX: 2(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Vd
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box has one lateral . No evidence of solids carry
over . No evidence of leakage into or out of the box .
PUMP CHAMBEPA4&/&0ocate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): .47,4
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump chamber is not present
8
Page 9 of I I m
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:22 Bay Road
Cotuit ,Mass .
Owner: John Jansen
Date of Inspection: 5/31 /02
SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan, excavation not required)
3- Infiltrators in series
If SAS not located explain why:
-Located ; See Dage 10
Te
aching pits. number:
leaching chambers, number: A-A1A•47A--4;"
leaching galleries, number: Q
leaching trenches, number, length: p
leaching fields, number, dimensions: p
overflow cesspool, number: > "
Q innovative/alternative system Type/name of technology.
Comments(note condition of soil, signs of hydraulic failure, level of ondin , dam soil condition d
p g p of vegetation,
etc.): g
Loamy sand to fine sand No signs of hydraulic failure
ar,= prind'Sng - Vegetation is normal
CESSPOOLS14XlL(cesspool must be pumped as pan of inspection)(locate on site plan)
Number and configuration: el
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum la\,er
Dimensions of cesspool:
Materials of construction: AR
Indication of groundwater inflow(yes or no):
Comments(note condition of.soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cesspools are not present
PRIVYA .(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.):
Privy is not present .
9
I
Pagc 10 of I I
OFF?CIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM 1NFORM;ATION (continued)
Prop<r-ry Address: 22 Bay Road
Cotuit , ass .
Owocr. a se
Djtc of Inspcctioo: 2
SKETCH OF SEWAC£ DISPOSAL SYSTEM
PTOridc c tkttch of the tcw11c ditpostl lyltcm Including ►Ics to el lcasl rwo permancnt rcfcrcncc landmarks or
o<n<Nntrkt. Lc<ctc cII wc111 within 100 feet. Locw where public water supply cnlcr$ the bvilding.
rotas woos
• O
3,LVG /
d10yS SE
!MOD 04
Rd ' ✓ / i
I �
I ''0
10
l
I
Page I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_
PART C
SYSTEM INFORMATION (continued)
Property Address: 22 Bay Road
Cotuit ,Mass .
Owner: John Jansen
Date of Inspection: S/31/0 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
t - I
Estimated depth to ground water oQ' feet
Please indicate (check)all methods used to determine the high ground water elevation:
?Accessed
btained from system desi t lans on record - If checked,date of design plan reviewed:erved stte abutttn / bservatton hole wt hi;t 150 fee�,of SAS)
cked with local Board of Health-explain: �AbA. 4141
cked with local excavators, installers-(attach documentation)
USGSdatabaseexplain: http ; town . barnstable , ma , us
You must describe how you established the high groundwater elevation:
sed ; Gahrety & Miller Model . -12/16/94 Ground. water elevations -above
sea level .
:sed ; USGS Observation well data . June 1992
sed ; USGS. Technical bull in 92-000-1 Plate #2 Annnal wa Pr table
round — —
elemations .
j�r-rUJ�O
b 'eet
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Fdmpter Method
Therefore, the vertical separation distance between the bolt m
Of the leaching pit and the adjusted groundwater table is ..1
feet.
11
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1 TOWN OF LVJARD OF HEALTH
-•F-T *-_'-^SUBSURFACE 9EHAGF; DISPOSAL SYSTEM INSPECTION FORM - PART D .' CERTIFICATION r l„•
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 22 Bay Road Cotuit ,Mass . '
ASSESSORS MAP , BLOCK AND PARCEL # 020-002.
OWNER' s NAME John Jansen
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P .Macomber & Son Inew
COMPANY ADDRESS Box 66 Centerville Mass . 02632
Street Town or CSty state LIP
COMPANY TELEPHONE (508 775 - 3338 FAX ( 508 790 _ 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
DrI-ecomme
his address and that the inforration reported is true , accurate , and
omplete as of the time of :inspection , The inspection was performed and any
ndations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Chec one :
System PASSED 1
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe environment as defined in 310 CMR 15 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILEll*
The inspection wtlicil I have con Ucted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 - 303 , and as specifically noted on PART "C - FAILURE
CRITERIA of this inspection form .
,r
Inspector Signature Date
ne copy of this c t.ification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEAL1'!t.
* If the inspection FAILED , the owner or"'operator shall upgrade
he ayste
within one ,year of the date of the inspection , unless allowed ortrequiredm
otherwise as provided in 310 ChJR 16 . 305 .
partd .doc