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0031 CAP'N CARLETON'S RD - Health
31 dap' .:r Carletons Road Cotuit - —- — —--- - - A= 038 061 i M 10/11/2019 ShowAsbuilt(1700x2800) TOWN OF BARNSTABLE uIr /t 1311b LOCATION // CAPI CAk�TBNisEWAGE U VILLAGE C 7&oeT ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. o 8_�mw— Cdl�''? 3 -.39057 SEPTIC TANK CAPACITY /41M /y LEACHING FACILITY:(type) C!r yrzQ, (sizc)rf�.X!Kf/ NO.OF BEAROOMS__J _PRIVATE WELL OR PUBLIC WATEIE/C-, BUILDER OR OWNER �yyy�yJS� -TO�YY/ttJs � DATE PERMIT ISSUED: J? 30 -,?Sr DATE COMPLIANCE ISSUED: !21-,�a--r Z VARIANCE GRANTED: Yea No o Cf�PT CfJ ��o https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=038061&sq=1 1/1 TOWN OF BARNS ABLE LUCAn-ON ® EWAGE # ,VILLAGE' ASSESSOR'S MAP & LOT 0:5 / INSTALLER'S NAME PHONE NO._ �� / SEPTIC TANK CAPACITY 'e , a LEACHING FACILI'TY.(type) �� °"moo ; (size)!7b.X 5,W NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERjj �®1�J� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 7""�-� G VARIANCE GRANTED: Yes No � . `� _ " i �-D �s � , a 0 � '. P� u I � \` i' ^ e 1, � � � � �"�, } �+V� � y� a �� j y !� .IV � No.. v. _...... Fps.... L. .. t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iration for Diripwml Midw C owitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: #j 6,# 31 ....................••• � L --------•- -•----....--•---•-• csti �• -- •- - ---- or Lot No. 'a(r� �s .... ...... / ...................... ................................................................................................. /�� Address Installer Address d Type of Building Size Lot---- a ,...Sq. feet V Dwelling—No. of Bedrooms-------------- ---------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons-_--__-__-------___--..-... Showers ( ) — Cafeteria ( ) dOther fixtures ------- -------_- ---•----•--•---•-•--•-••------------------- ----•----------:....._....................................................... W Design Flow.................................4;i5 ..gallons per person 2er day. Total daily flow....... ........................gallons. 9 Septic Tank—Liquid capacity/..49-gallons Length_ -_4,_.. Width-.4-.X--- Diameter--.r.... Depth_..-.k .... Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No................/... Diameter._.--- /..:._..... Depth below inlet..._...4�......... Total leaching area.... ...sq. ft. Z Other Distribution box Dosing ank ( ) aPercolation Test Results Performed .................. Date.,/� ,.� Test Pit No. 1.495.�'�-minutes per inch Depth of Test Pit.-- Depth to ground water.... '........ fZ Test Pit No. 2.........` --_--minutes per inch Depth of Test Pit....X n..__._.. Depth to ground water-_- --..--_--. R+' ------------------ -------- ----.... ---•-•-------- .............. •.................................. x Description of Soil... .� �� .... �c.e`!>---------------=----------•------------• U --------------------- ------•---------------------------------------- •------------------------------------- •-------------------------------------------------------------------W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ............................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Comp ' ce een issu by th oard o alt Q Signed ------- .. . .. ............... . .. ......... . ----------- ......3.�/./J1 D.. ...:.L. I Uace ApplicationApproved By - ----------- ... ... .... ... ............................... ........................................ Date Application Disapproved for the following rear n : ........................:...................................................................................... Permit No. . ... . • ....... Issued ...........: _ �FR (�} No.. ....--............ s A !.1..�.. THE COMMONWEALTH OF MASSACHUSETTS -BOARD OF HEALTH TOWN OF BARNSTABLE Applirativit for Di!ipwial Works C omitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair. (�.�) an Individual Sewage"Disposal System at: `j f7 r A 2 Lr�T�!V I_Z�. ( V.r ..................... 1!�•...--•--------------•----•-.......•--....-----••. Lor^on`A�9ress r r or Lot No. «ner Add .................D.66_......... Installer Address U Type of Building Size Lot. .. _ ...Sq. feet �--t Dwelling— No. of Bedrooms................3._..............-----._.--Expansion Attic ( ) Garbage Grinder ( ) 0`4 Other—Type of Building ---------------------- ----- No. of persons.--------.------.-.-.--.-.-- Showers ( ) — Cafeteria ( ) a'I Other fixtures ......................................... W Design Flow.................................: gallons per person per day. Total daily flow-.---�.30.........................gallons. WSeptic Tank—Liquid capacity/./�,P4.galIons Length-JF-4.-.- Width--¢-.�--- Diameter_- =----. Depth-_5.:.�t�....-. x Disposal Trench--No. .................... Width..........--...----- Total Length..-----............. Total leaching area....................sq. ft. Seepage Pit No----------------j--. Diameter...... ......... Depth below inlet..--..�f.......... Total leaching.area.... z...sq.-ft. Z Other Distribution box (v) Dosing tank ( ) Percolation Test Results Performed by...,4...C'. !:: .................. Date./O.-1::..5y----_--.--.---- ,.I Test Pit No. 1.4.F.4K'Xminutes per inch Depth of Test Pit--.; Depth to ground water.---:!—........ rZ4 Test Pit No. 2........"......minutes per inch Depth of Test Pit----/Zr........ Depth to ground water....�f.......---. 04 ............ --- -----------------------------------•--••--••----------.....--•---.............-----------•---•-•. -------------- D Description of Soil..1... ... ....... .... .r x ...................•-------•-•---...-----------------------....--------------•----•----.....................----..........=" W ....••---------------------------------------------------------------------------------•------------------------------------------•---------------------------------- ............ -----•-------........ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compla•xtice has,been issued/by thelb"oard ofO ealt . �. C A/ l Signed ......../ ... ./ ... r./ ; ....../''- _ -..:. /7.(`...:.. 1 Application Approved B --- !OVA ........fit :© - fi; "-• 'f. / i _..... PP PP Y v r v Dace Application Disapproved for the following ream / ......- ....................................................... ........................................................... ....................................................,....r_. .,.. .................................. . . ..... .... ........................................ .. ..... /.... .............. .... Permit No. ...- .4 ......./ ! Issued ............ .!. _ ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ger#tf ra e of Compliance THIS IS TO CERTI , That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ................................................. . - -6-......------... �._............... ------- ....---------- -------*................. ......................................... ..-.. OA at ..............W_,:f#--a.... ,----- /_.. R 6 has been installed in accordance with the provisions of TITLE of The • tate Environmental Code as described in the application for Disposal Works Construction Permit No. . `:�9'. _.._.. dated _.__.........._....................._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .r, .� �J"ti/ �� DATE..... - ---------------------- Inspe o THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF HEALTH TOWN OF BARNSTABLE --� No...!t ........ FEE........................ Disposal IUDr v Tomitrurtivit ramit ��Permission is hereby granted-------...��.:-.-��-.--•---------•��-�-------------------------•------------------•----•-----•------...--••---........-•--- to Construct (4,' or Repair ( ) an Individual Sewage Dispo ystem n/ �} �•!at No.- frl ` Jfi �(...' T L� as� ��1 �.. ��1' 1 il_._� a-:.(-�.---f...1...._. L , Street as shown on the application or Disposal V1'orls'Construction Permit No'.fl Ated-------------- n /Board of Health DATE..........�•__••1------------- ........................... % FORM 36508 HOBBS&WARREN.INC..PUBLISHERS •`_.� y, _ ._.._..__.-_.__- __._____._..-----_-_.__._.._._ ___..___.---_.._ __ _._.______.�.��,.-gig ��.i , 49 / t4ti Cape Cna.�inee,- 49 Natbot loud ' i Capp 50.0 J�Na#lji4 ., -PA 02601 Cat P n !?oad caia �� I ;} Flo wide j -t 4 qai • 1 1 4(o'!CIO el40. I I . A P \ Vs i \ . N0 IVO i vi I i � ' AFL• . j �'� �...`_� • v S i fat i q6� ! 1 I ' i 'Pot al 0.83 0 ad q q ;- J .., s 46 49' z 4do I � • tot 4a ��.ti�s+.�ted� .Cot �330 •mod 'pot 45 a Ti - /000. o00 ,...i �I• ,' tit :� raJ12 'stone Sk-,tch P ta,i o .L'c�ul .i.N. Coxt 9o2 Oa ,, 9. 9oh*%,on I+4 6eAA9 ,jot��/! a� ahown ors --NC.:'13,1623 13'�A 3 _. .., .._ ._.... �......_.... i £�e�Jc ter orv� ace ovi an,a tutz�d datu si. i J�:it #p-8 3 30 � Made J/2-6-9�1 t � i:. ' .i ; .art. -cd. No wa te2 enco uvi,�,ehed , eicc /� n Ceram 2 ►wut eh l � 5 416.4, A� medium p 4z,b • I _1 i ' Commonwealth of Massachusetts a38- OW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,••'' 31 Capin Carelton Property Address p, Jackson Owner Owner's Narr� information is ✓ required for Cotuit MA 10-1-17 every page. Cityrrown 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC "�11 Company Name P.O. BOX 145 Company Address CENTERVUE MA 02632 City/Town State Zip Code 508-420-4534 S14297 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 ❑ Needs Further Evaluation by the Local Approving Authority 10-1-17 Q419rls - 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. �Ttd Vl5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal SyPage 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. 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: ® 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: At time of inspection system met all minimum passing requirements. The leach pit was not opened due to the depth. The d-box was viewed by camera and was found to be in working condititon with water flowing into the leach pit. The system was installed in 1995 per as-built card. This report can not predict the future performance under the same or increased usage. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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: ❑ 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is Cotuit MA 10-1-17 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , ' 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 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 El El Area 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Capin Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. City/Town 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 been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 l t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is Cotuit MA 10-1-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: According to as-built card this system consists of a 1000 gallon hd septic tank d-box and an h-20 leach pit Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N.A at time of 9 ( Y 9 (gP )) insp Detail Sump pump? ❑ Yes ❑ No "Last date of occupancy: currently occupied .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 Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Capin Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupied Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes-® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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 1/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1995 per as-built card Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3 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 hd Sludge depth: moderate t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness light Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? wooden pole Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend pumping at time of transfer and every 2-3 yrs thereafter for maintenance. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 31 Capin Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityrrown 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.): Box was viewed by camra and showed no signs of failure at time of inspection. 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: depth of pit was unable to safely reach t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every 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.): 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 t5ms-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Capin Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 31 Cap'n Carelton Property Address Jackson Owner Owners Name information is required for Cotuit MA 10-1-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 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 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 31 Cap'n Carelton Property Address Jackson Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. City1rown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 2 of 2, http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=038061&seq=l 10/1/2017 .Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE (�1 /(�'j // i j LOCATION I t7f y/ cA0?7 CA�LT®a)AEWAGE# VILLAG er ASSESSOR'S //MAP& LOT INSTALLER'S NAME& PHONE NO._�,FCQ SEPTIC TANK CAPACITY .) �• LEACHING FACILITY.(type) ��'' -ef�-2B (slze)J' NO.OF BEDROOMS WELL OR PUBLIC WATER BUILDER OR OWNERhjS� DATE PERMIT ISSUED.-- DATE COMPLIANCE ISSUED VARIANCE GRANTED: Yes No 7. fi2�/vP� O br 'kt�1 - C14)07• 0/1 6;ro hap://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=038061&seq=1 10/1/2017 BARNSTABLE COUNTY REGISTRY OF DEEDS DEED RESTRICTION WHEREAS,'.' fy C�j G 4 Jt#AA16 4? _,...lg6�N 'of 31 e4we VIVC; 12491) (owner's name) (address) e'oTu%r MA is:rthe owner-of a SINGLE FAMILY .., RESIDENCE ,MA (address) and being shown on a plan entitled "Subdivision of Land in 67ktT MA, Property VIA of 11eA016 U Jf��£-A• -J.9cr&oAJ , duly eecor'dedin Barnstable County Registry of Deeds in Plan Book 3 s� Page 7 t 9 , WHEREAS, 11510a b G,. Jf4Mvf ,Q JVdO4 as the owner of.said lot has agreed (owner's name) with the Town of Barnstable Board of Health to a restriction as to the'number of-bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal work construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; I WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, w State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of v„ Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, NOW, THEREFORE, APoC9 t �ff�*A'-C � dyd-CoN does hereby place the following restriction on his above-ref a cad land in accordance with his agreement with the Town of Barnstable Board .of Health, which restriction shall run with the land and be binding upon all successors in title: may have constructed upon the lot a house containing no more than bedrooms. Agee} G Jf'p wf 'heluely (owner's name) agrees that this shall be permanent deed restriction affecting 3/ 401,v Iy2frroN�' 90 , (address) / i> MA, and being shown on the plan recorded in Plan Book Page Executed as a sealed instrument 10 day of 20a9. Owneek signature My C.omn a►� ..bon Ow ne s 'ignature r Aj ' Commonwealth of Massachusetts Title 5 Offcil- Ins action Form Not for Voluntary Assessments Subsurface Sewage Disposal.System Fonrj Inspection results must be st bmitted on this form or on the official Title S inspection Form dated 6/15/2 w.Inspection forms rot be attemed in any waX A. Certification v 1. ProPe tome an theon:� nl 014,1 _GMV go tab k" Prc - dtDaw"o not ` we ffse romm ZOM �a skft Zocoft Date of lnspecftL 2 Dat ills e N fnspK cxty/rown Sfaie ZO O*& Terse�mber C, Certification Statement; Irrfor*�t I have personally inspected the sear �betaw� age disposal system at this address and that the was pe formed based on my�a�and complete as of the time of the in ail:.The irsp�tlon age disposal syslerr�.1 am a DEP �in the prober f Mction and malntenanc a of od'site Title 5(310 CMR 15.000).The system: system inspector pursuant to Section;15-W of ; > asses 0 Con =� dftionagy Passim Q Faits Needs F Evahration th L rovinge Yto The system inspector shag submiit a�pY ctnspectionhe of Health of DEP)within 30 days of completing this Inspection.tf the � �Authority,end has a design flow of 10,tm0 gpd or greater,the inspector and thetem is a shared system or report to the appropriate regional office of the DEP_The- owner shall submit the original should be seat to the system and copies sent to the buyer,iE applicable.and the approving authority.and "'*This report only,describes conditions at the time of inspection and under the condition of use at that time.This Inspection does not address how the system will perform in the future the same or diftrent conditions of use. under .dOc•11�004 We 5 OBfchsl bnpecem Form 3g.,surtam Sewage Df VMd Sy_ Paffe 1 of 16 Commonwealth of Massachusetts - Title 5 Offficial ins eC ' laot for vol p tion Form SubsurfaceforVo uSewage asoosal System Form A. Certification (font) ap Cola Dft of inspection&MvrMT.Check A,B,C,D or E I always complete all of Section D A) Syaftm pass": "e not hound any k*wM lion which Indicates that In 310 CMR 15.303 or.in 310 CMR 15.304 exist �lL Me�� txitelia did Indicated below. Any failure not evaluated are Comments: */AWM C .onditiona nY Passes. ❑ One or more system components as described in the'Con pa•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 determined;please explain. following statements.If"not ❑ The septic tank is metal and over 20 years old'or the septic tank strudtaally unsound.exhibits ti. (whether metal or not)is System will pass inspecticrr if OW existing tan AMP withOr extiltration or tank f complying se is imminent. wed by the Board of Health.A metal septic lank as * septic tank will pass ikon if it is structurally soun4 not leaking and if a Certillcate of ling that the tank Is kiss than 20 ND Explain.- years old is available. Title 5 Ott rnSPOCk,Earn+S System Page 2 of le rommonwealM of 1dlasSachusetts - Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont) 0. ^/ DOcoft M&or r n B) System Conditionally;passes(coat.): ❑ Observation of sewage;,backup or break out or high sbft water level in the distnbution box due to broken or obstructed,pipe(s)or due to a broken,settled or uneven distribution box.System wig Pass ins 9(with approval of Board of Hoaith� ❑ broken pipe(s)are replaced ❑ obstruction is rived ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The / system van Pass inspection if(with approval of the Board of Health): ` ❑ broken pipe(s)are r&ced ❑ obstrU uciion is removed ND Explain: . I /i C) Further Evaluation is Required by the Board of HeaMr IA ❑ Conditions,exist which require furor evaluation by the Board of Health in order to determine if the system is Wing 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 wm protect public heaf safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or Privy is within 50 feet of a bordering vegetated wetland or a salt marsh shlsp.doc•1112M TMO 5 Offidal kq*c m Fomr Submaraw sewage Dbpxw system. PRge3of16 r Commonwealth of Massachusetts Title 5 Official. Inspection Form Not for Voluntary Assessments Subsurface Sewage Disp6sal System Form A. Certification (cont.) C", LQ CWT—O*n ate code E Iry E�'i OW Ws Daft of�w C) Further Evaluation is Required by the Board of Health(cont.): PA, 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 tn"butaiy 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 we& ❑ 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.detemnine distance: This system passes if the wen water analysis performed at a DEP certified laboratory,for collform bacteria and volatile organic compounds Indicates that the wen Is free from pollution from that facility and the presenoe of ammonia nWogem and nitrate nitrogen is equal to or less than 5 ppm.provided that no otter failure cnU to are tiiggered.A copy of the analysis must be attached to this form. 3. Other. I i5insp.doc-1112004 TMO 3 OWCU fropection Form:Samoa e DjspWW s - Pape 4 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification {cone} cey LSwIft _L� �AN(�'1 /j� c r 5 . UCH Owr 's Name Da6e of D)System Failure Criteria Applicable to All Systems; You must indicate"Yes"or=No"to each of the fodowing for all inspections: Yes No ❑ i�1" 8wkup of image into facility or system comPonert due to overloaded or !� dogged SAS or cesspooi ❑ /tg_ Disdr e or l�olng of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or Wigged SAS or cesspool ❑ i_iquid depth In cesspool Is less than(r below invert or available volume is tens than 4 day flow ❑ [�' Required Pumping more than 4 tunes in the last year NOT due th dogged or 7 obstructed pipe(s).Number of times purnped• ❑ Any portion of the SASS privy is below high ground water elevaeorL ❑ Any Peron Of cesspool or privy is within 1()o feet of a surface water'supplyor tributary to a surface water supply. 0 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 ❑ Any portion of a cesspool or prhry Is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis,[Tt item Passes If the well water anabsig.performed at a DEP certified laborgDry.tI coliform bacteria aW votatlte organic compounds Indkates that the well is*00 from polludon from that facility and Ure Presence of ammonia nIt and nitrate nitrogen Is equal to or less than5 ice.Provided that no o"ter failure criteria are WWenxL A copy of analysis must be attached to this forma Yes No _ ❑ y The system falls.l have determined that one or more of the above fallure criteria exist descried in 310-CHAR 15.303,therefore the system fads.The systern owner should contact the Board of Health to deterrnine what will be necessary to coned the failure. «Sp.�c-111Z004 Tice 5 O&W M%)&*w Form Subsurface Sawage Dbposd System page 5of16 Commonwealth of Massachusetts .Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. certification (conq tTf,✓ � L os Oaft of E) Large Systems: To be consWered a large system the system must serve a faulty with a design flow of 10,000 gpd to 15,000 gpd. For large systerrM you must indicate either"yes'or`nd'to each of the following,in adMon to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface dr inking water supply ❑ 0 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 7. MPA)or a mapped Zone If of a public water supply well If youor h red answered'yes* to any question In E the system Is considered a significant thn� "des"in Section D above the large system has failed.The owner or operator of any large system considered a slgntliicant threat under Section E or Wed 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 ft"doc•11MM Tdle 5 O knpecbon Fomc Submma=Sewage Dbpmd Sysftm Page s of is Commonwealth of Massachusetts Title�r 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist pwperti ff • p s _ �1 stab Zip Code ownerslu— Name oats of Check if the following have been done.You must indicate"yes'or OrW as to each of the fbitawing: YES NO ❑ Pum ping Information was provided by the owerer,occupant,or Board of Health Were any of the system componenrts pumped out in the previous two weeks? ❑ Has the system received nornei flows In the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? qi ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ❑ Was the facility or dw►eiling inspect for signs of- Sewage back up? p ❑ Was the site inspected fbr signs of break out? ❑ Were all system components,excluding the SAS,bated 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 flquid,depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if ddfererrt from owner)provided with infonrration on the proper Maintenance of subsurface sewage disposal systems? The size and location of UM Soil Absorption Sysfm(SAS)on the site has been determined based on: ❑ Existing iMorination.For exampb,a plan at the Board of HeaWL ❑ Detwnlned In the field(if any of the failure crfteria related to part C is at Issue approximation of distance is unacceptable)1310 CMR 15.302(3Xb)] UWIspdoc•1MAIM Tdb 5 OffkW rnspecffm Form:Subsurface Sewage pisposa hem. Page 7 of 16 y Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Volunbry Assessments Subsurface Sewage Disposal System Form C. System 1 orma 'thy le, �-- _ state Zip Code ow mes Name Date of h" Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DMIGN flow based on 310 CMR 15203(for example.110 gpd x#of bedrooms): Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?fif yes separate inspection nequiredl ❑ Yes'N/No Laundry system inspected? `(Yes ❑ No Seasonal use? ❑ Yes No Water meter readings,if available(last 2 years usage(gpd)): " Sum pump? ❑ Yes NO Last date of occupancy. "'"�j�"✓� f CommerclaUtndustrial Flaw Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203k Gaftm per day(gpd) Basis of design flow(seals/persons/sq ft,etas. Grease trap present? ❑ Yes ❑ No industrial waste holding tank present? ❑ Yes ❑ No Noh-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings.if available: Last date of occupancy/use: Dare Other(describe): tS l doc•!U2a04 Title 5 OMCkd t ran FbnM 3 8 OIsposat System Pegs a of 16 . Commonwealth of NWSSachusetts .Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (corn.) c Z7 ownis Av�62J � �---- Q¢� state zOCOde OvCW— s Ndme Date.at hm General Information Pumping Rewrft: Source of information: Was system Pumped as pert of the inspection? �es ❑ No It yes,volume pumped: How was quanft Pumped determined? e'er Reason for pumptmg: 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 rec Wj%if arty) ❑ innovafive/Aitemative technology.Attach a copy of the ament operation and m*t rMm Contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): AppnoAmate age of all components, installed(if known)and source of information: Ie 7n Were sewage odors detected when arriving at the site? ❑ Yes No t56mpdoc•11/2004 Tutor 5 Off tnspecrjon FOM Sutrsmraw Sewage DbPOSWsystem Page 9 of 18 Commonwealth of Massachusetts Title 5 Official. Inspection- Form Not for Voluntary Assessments Subsurface Sewage Dispml System Form C. System In rmatkon (cont) :A, ( 4drd, Ciit tM / sae coda tt 6� ��'l►C�/t�-2� a�i�... � � � Dale of Building Sewer(locate on site plan). _J Depth below grade: test Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of tents,venting,evidence of leakage.etc}: Septic Tank(locate on site plank. Depth below grade: f feet Material of construction: O'concrete ❑fiberglass ❑polyethylene��� ❑other(explain) N tank is metal,list age: 188 ageconfirmed by a Certificate of Compliance?(attach a copy of Yes 0 No Dimensions. f Skidge,depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness Distance from top of sc urn to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Hoar were dimensions determined? tsmp_dne-11P.Z004 1WO 5 MW kgxx f n Form Submrftm Sewage ObPWWSys- Page 10 of 16 Commonwealth of Massachusetts Title 5 Officia! !n s ectlon Form p . Not for Volu marl/ Assessments Subsurface Sewage Dimposai System Form C. System I ormation t.) ell SW s t . o Date of hqACOW,1,- Comments(on pumping recommendations.inlet and outlet tee or baffle condition,structural Integrity, liquid levels as related to outlet Invert,evidence of leakage,eta): gn Grease Trap(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal 0 fiberglass polyethylene other(e)pleiny r 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 fast pumping: Date Comm8rds(on pumping recommendations,inlet and outlet tee or baffle condition,struchual integrity, liquid levels as n*ftd to outlet invert.evidence of leakage,eta): 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 0 polyethylene other(e*faihy Mrlsp.doc-111 M Tice 5 O&ai Form:Subsuftce Sewage Dbpmd System Pegs 11 19 I Commonwealth of Massachusetts .Title. 5 official Inspection Form Not for Volun tart'Assessments Subsurface Sewage Disposal System Form G. System information (cons) Ad r r- :� 6.2 -E W — o� --�-� 1*0odi Owrlws Tight or Holding Tank(cant.) Dirrnenstons: /Q/4 Capacity: I Design Flow: vamm per day Alarm Present: ❑ Yes ❑ No Alarm level: Alarm in workingorder, ❑ Yes❑ No Date of last pumping: Comments(condition of alarm and float swiUm,etc.): Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.etm): rump Chamber Qocate on site plan): a Pumps in working order. ❑ Yes ❑ No Alamo in working order. ❑ Yes ❑ No 15hw.aoc•11/2004 Tide 5 ord rrwpec&m FOW subsudaw SewageDtVOWSV818m Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C- SYstem Information r�7Adlms state - Zip Code Owners NameDat ;swtuon Comments(tote condition pump chamber,condition of pumps and appurtenances,etc.r i { Soil Abso rptlon System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: F 3 Type: f teaching pits � number: — ❑ leaching chambers number. ❑ leaching gaileI'es number_ ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: d overflow cesspool number. .❑ innovative/alt imative system Type/name of technology: Comments(torte vegetation,etc.): condition of soil,signs of hydraulic failure,level of ponding,damp sod,condition of � . ' b t"f1ns/•�-11fL W Title 5 Official Inspection Form:Subsurface sewage Disposal System Page 13 of 16 i COl{It110lIWed1tlt Of Massa' ctwsetts `title 5 Official Inspection Form Not for Voluntwy Assessments Subsurface Sewage Disposal System Form I C. System IrKormadd t) r • 1 �7( 01IYr1 'UP v,.a s oar of Cesspools(Cesspool must be pumped as of Pact Inspection) orate on site I - � an . P , Number and oatrifrguratlon � A/11 . 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.): i I PrIVY Vocals on site plan): Materials of conshuction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic faflur e,level of pondfig,condition of vegetation, eta): I i Title 6 Of 1CW kwpecbm Fam Subsurface a Dbposef Sys- Page 14of16 i I I I Commonwealth of Massachusetts Title 5 Official Ins ection Form Not for Volunta rY Assessments Subsurface Sewage Disposal System Form i G. SYStem Information cont) see _ /�-�t✓:-v 1?-'� ! ' Zp Code Owners Data n Sketch Of Sewage Disposal m:Provide a sketch of the sewage disposal system lrx*ang ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet Locate where public water supply enters the boring. i i 3 I 1 . , l3C b A C 4 3� t5msp.doc•11/20Q4 Title 5 Oftal tnspectim Fomm Subsudace Sewage Disposal Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Farm UVNot for Voluntary Assesslments Subsurface Sewage Disposal System Form C. System i iformation (cont.) re-) �S Rd, Prope ddre�ss Iii city.C— r1 J®2�! ,�`j►e) State Zip Code o Owner's Name Date of Ins ction i Site Exam: I Slope j Surface water I Check cellar Shallow wells Estimated depth to ground water. , i I Please indicate all methods used to determine the high ground water elevation: Obtained from s YIstem design plans on recor d If checked,date iof design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: i ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS;database-explain: s 1 You must describe ho esta d th�gro nd water elevation• �--- �rou , � i l5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System Page 16 of 16