HomeMy WebLinkAbout0124 CAP'N SAMADRUS ROAD - Health 124 Cap'n Samadrus Rd
Cotuit
A= 038-044
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
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:When filling out A. General Information
forms on the IL
computer,use 1. Inspector:
only the tab key u
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
�00 City/Town State Zip Code
(508)428-4028 S14454
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:
«...,., 9 3 e 7
® Passes ❑ Conditionally Passes ❑ Fails Q
❑ Needs Further Evaluation by the Local Approving Authority j
l�
1/31/2011
Inspect is 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. /
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Se a Disposal System I•Jage 1 of 17
P 9 P Y
i #
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M ,•''y 124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is Cotuit Ma. 02635 1/31/2011
required for i
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:
The septic system is in proper working order at the present 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.
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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is Cotuit Ma. 02635 1/31/2011
required for �
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
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 S
❑ ® 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•11110 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 124 Capin Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
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
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 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
G M 124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-11/10 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
124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents.
2 I'
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 1/31/2011
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? •❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
N07Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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 I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11110 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
M , 124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owners Name
information is required for Cotuit Ma. 02635 1/31/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through house vents.
Septic Tank(locate on site plan):
Depth below grade: 2.5'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gallon
Sludge depth:
6°
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness 411
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
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 tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
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•11110 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
124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
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
l5ins•11/10 Title 5 Official Inspection Forth: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
124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
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 No
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 is Ievel.Box has one outlet alteral.No evidence3 of solids carryover.No evidence of leakage.
Y,
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4 rechargers.
❑ leaching galleries number:
leaching trenches number, length:
❑ 9 9
❑ 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.):
Saner soil.No signs of hydraulic failure.No ponding or damp soil.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 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
124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
every page. Cityrrown 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 114 of 17
- THE FOLLOWING
IS/ARE THE BEST
IMAGES .FROM POOR
QUALITYORIGINAL (S)
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DATA
Commonwealth of Massachusetts
• ``�
T` Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
124 Cap'n Samadrus Rd.
r Property Address
gig: �..
} " Robert Caprio
Owner
Owner's Name
information is 4� required for
Cotuit Ma. 02635 1/31/2011
'
every page. Cityrrown I State Zip Code Date of Inspection
D. System Information (cont.)
Ske�eh 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:
,r
❑ hand-sketch in the area below _
❑ ,�rawing,attached separately
wpm ?
b
d �%m� 3Z
y
70 V'+,1C-
r 41
A To
q vx Zb
g D �
i
t
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t5ins-11110 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 124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
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: Bottom of leaching 30'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:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001, plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 124 Cap'n Samadrus Rd.
Property Address
Robert Caprio
Owner Owner's Name
information is required for Cotuit Ma. 02635 1/31/2011
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
inspection Summary: A B C D
® P rY , 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
1
1� �C�D
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
CERTIFICATION
Property Address: 124 Captain Samadrus Road
Cotuit MA 02635
Owner's Name: Robert Cori
Owner's Address: (�
Date of Inspection: October 3 2007
Name of Inspector: (Please Print),James M. Ford t
Company Name: Jdnies M. Ford
49
Mailing Address: P.O.Box
Osterville MA 02655-0049
40
Telephone Number: (508 862-9 0
cn�
='
jt
CERTIFICATION STATEMENT
I certify that.I have personally inspected the sewage disposal system at this address and that the infonnation.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 iY�aintenance 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
Ne s Further Evaluation by the Local Approving Authority
Fa s
Inspector's Signature: Date: October 14, 2007'
.The system inspector.shall subs t 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 6/15/200.0 page 1
o
Page 2 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 124 Captain Sainadrus Road -
Cotuit. MA
Owner's Name: Robert Caprio
Date of Inspection: October 3. 2007
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:
B. System Conditionally.Passes:
One or more.system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years.old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial.infiltration or exfiltration or tank failure is iimminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if'it is structurally sound,.not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain: .
The systein 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
Page 3 of 11
OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 124 Captain Samadrus Road
Cotuit, MA
Owner's Name: Robert Curio
Date of Inspection: October 3, 2007
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 mariner which will protect public health;safety and the environment:
Cesspool or privy is withih 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that.protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has aseptic 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,perfonned'at a DEP certified laboratory, for colifonn
bacteria-and volatile organic compounds indicates that the well is free from pollution.from that facility and
the presence of aminonia 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:
Page 4 of 11
OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 124 Captain SanWrus Road
Cotuit, MA
Owner's Name: Robert Caprio
Date of Inspection: October 3, 2007
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/2.day flow .
' e in the last year NOT due to clo ed or obst
ructed i e s . Number
— ✓ Required pumping more than 4 times y clogged p P ( )
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 I 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 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.]
No (Yes/No)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 System:
To be considered a large system the.system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 I1 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.
_4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST .
Y p
Property Address: 124 Captain Sama&us Road
Cotuit, MA
Owner's Name: Robert Caprio
Date of Inspection: October 3, 2007
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 backup? .
✓ 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:
Yes No
✓ _ 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 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 124 Captain Samadrus.Road
Cotuit, MA
Owner's Name: Robert Curio
Date of Inspection: October 3, 2007
FLOW CONDITIONS
RESIDENTIAL
Number.of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n1a
Is laundry on a separate sewage system(yes or no): . n1a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No t
Last date of occupancy: Currently occupied
COMMERCIAVINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203)- gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records .
Source of information: Never pumped-per owner
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the PEP approval
Other(describe):
Approximate_ age of all components,date installed(if known)and source of information:
Installed on 1131100-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7,of 11 ;
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 124 Certain Sainadrus Road
Cotuit MA
Owner's Name: Robert Caprio- .
Date of Inspection: October 3, 2007
4 ,
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 22"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
other(explain)
If tank is metal list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 5"
Distance from top of scum to top of outlet tee.or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on purnping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert, evidence of leakage, etc.):
The liquid level was even with the outlet invert There did not appear to be any signs of leakage. Recoinnnend installing risers
to bring the cover within 6"ofgrade
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet fee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recomimendations,'inlet and outlet tee'or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc'.):
7
Page 8,of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 124 Captain Samadrus Road
Cotuit MA
Owner's Name: Robert Caprio
Date of Inspection: October 3, 2007
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alanri in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: _ ' ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D box was clean No solids were present
PUMP CHAMBER: None (locate.on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address: 124 Captain Samadrus Road`
Cotuit. MA
Owner's Name: Robert Casio
Date of Inspection: October 3, 2007
SOIL ABSORPTION SYSTEM(SAS):. ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 4-Cultec rechargers (35'x'12'x 2'-per as built card)
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.):
The chmnbers were clean There did not appear to be any suns offailure A video.camera was used for the inspection.
CESSPOOLS: None (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: f
Indication of groundwater inflow(yes or no):..
Continents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation-,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Coiiunents(note condition of soil,signs of hydraulic failure;level of ponding,condition of vegetation, etc.):
9
Page 10 of 11
• OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 124 Captain Saniadrus Road
Cotuit MA .
Owner's Name: Robert Curio `
Date of.Inspection: October 3, 2007.
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells.within 100 feet. Locate.where public water,supply enters the building.
CArA
S
10
Page 1.1 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 124 Captain Samadrus Road
Cotuit, MA
Owner's Name: Robert Caprio
Date of Inspection: October 3, 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 50+/ feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-.If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked.with local excavators,installers (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours nial2s the inaps were showing approximately 50'.+11-to groundwater at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
fitnction property in the future. There have been no warranties or guarantees, either expressed, written or implied;
relating to the septic system, the inspection, this report and/or.any components of the septic system which have not
been located and inspected. -
{
11
Town-of Barnstable
p 1HE 1p�
Regulatory Services
-saxxsrnat,E, Thomas F. Geiler,Director
p$ '1639. ��� Public Health .Division
ATEO��A
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts,Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should.have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
i7t2 )/oa-c c1L q
,=JZ a � V
g
TOWN OF BARNSTABLE
LOCATION i ZA C SNiA AN D2-j?5 K Cl SEWAGE #
VILLAGE. ��c'r ,p ASSESSOR'S MAP & LOT C?
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY S� G� L'
LEACHING FACILITY: (type)
CO I+ek- re-d rQE'rS (size) 'T S ! Z Z—
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: Z—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 j
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
a
I UWII Ul Darllataule P#
Department of Health,Safety,and Environmental Services P--1�E3 7
Public Health Division Date A::t -(�
367 Main Street,Hyannis MA 02601
BARNBTABLK
"r16 �, Date Scheduled v�k w �0�. &r)o Time l 6)C.-A61, Fee Pd. t1
Soil Suitability Assessment for Sewage Disposal
Performed By: S ttUX, Witnessed By: Do ny)? f e-"4 VA J t
...
'LNMAtQ kQv T N
.. .Location Address 1Z4 GAF4. S&V.J.ws VJt Ce+vad Owner's Name RC. ,P'r10
I'✓o : 13 zoIS
Address o t—o 4 , M rk OZ&3 S W
O Assessor's Map/Parcel: Engineer's N
O Map * a cl 4 ame Stt-m Lo(Ift,
N NEW CONSTRUCTION REPAIR Telephone#
CX
! i
�—J Land Use YZ si u'tt" Slopes(*/o) Surface Stones
Distances from: Open Water.-Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate, etlands in proximity to holes)
3
�7'
to
Parent material(geologic) Depth to Bedrock
s
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
YIINA'i'ICMN-'Ott ..S ASb ATE H' A`Y"1JK mA$T. ;:: .<.
Method Used:-
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# __...._.. .Reading Date:.__..__._ Index Well level.,,_._' Adi.factor __Adj.Groundwater Level
.
PRCOLAT ON TEST Aatc fzi►ne:; >;.::::. .:.
_...........................................................................................................................
Observation
Hole,# Time at 9"
Depth of Perc ` 'Time at 6"
Start Pre-soak Time @ t u:3o Time(9%6")
End Pre-soak li vac b Sa�vrcod
Rate Min./Inch ess a-tn.... 2
Site Suitability Assessment: Site Passed te�"' Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back.
Copy: Applicant
. . .
.: ..
Depth from Soil Horizon Soil Texture Soil Color,: Soil Other
Surface, (USDA) (Munsell) Mottling (Structure,Stones,Boulderes,
a
o Gravel)
zo
/
DEEP OBSE tYA'Ti0 HOLE LQG F of #
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling. (Structure,Stones,Boulderes.
tGravel)
sGn�j. /oa»� 7 5 y2 S/g,
C 7
/4-
>EEP OBSERUAI'TON kIOE Y.00 Dote;
Depth from Soil Horizon Soil Texture Soil Color Soil-•- Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Gravel)
1�EEP OBSERV,�,MN HOLE I.UG HQie
. . .
..�. ».; .
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
0
Flood Insurance Rate Mao:
Above 500 year flood boundary No Yes t/^
Within 500 year boundary No V Yes Y
Within 100 year flood boundary No ✓ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? eee.::5
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on /il (date)I have passed the soil evaluator examination approved by the
Department of Envlronmental Protection,and that the.above analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR 15.017. .
Signature Date /" 1/ OV
7 '
TOWN OF BARNSTABLE
LOCATION / C.
4 S M 2 ruS SEWAGE# 10Ub
VILLAGE Ccrrvt' ASSESSOR'S MAP&PARCEL Olt- DC(y
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY /SW
LEACHING FACILITY:(type) C V hw (size) 3S X 1 a x a
NO.OF BEDROOMS y'
OWNER Cr4Pri 0
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 FOr2 l0 3 07
l
3
c�
a
1
Y
n
oI 09 C�
TOWN OF BARN,S�TAyyBLE
1
LOCATION I Z4 1.AP • SAIIAE-NDeO'S SEWAGE#
VILLAGE Ccno rr ASSESSOR'S MAP&LOT 0 101/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I SCO Gr-4,L -
LEACHING FACILITY: (type) CU I t^�r erS (size) 1 3Al ?-,
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: t Z-Z'7— ?-di;rV 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
Q
Ll
A t0 'mor- z.(® A rtb MIDDLE J C6m6er �Z
ib tAr le- <�' -Z> M i D DLr 6P
J
_ _ Y
No. t�IIJ�� � Fee lop
tHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �,es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2ppiication for Mi5po5al &pftem Construction Permit
Application for a Permit to Construct(x)Repair( )Upgrade( )Abandon( ) EXComplete System ❑Individual Components
Location Address or Lot No. 1z.4 Ce,p} , $cw.,wst r..s 12`Q Owner's Name,Address and Tel.No.
Cc FU�t; 1206- t- Cca13ri0 /1
Assessor's Map/Parcel 0-0. 6cnc •Z c9{S �
w+r+w 3$ Pt-i. Cc> h-v 6 Z6 S
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
0 Fc ry i(�f OZ fo S S
Type of Building:Dwelling No.of Bedrooms Fd u r- Lot Size 2�&6 sq.ft. Garbage Grinder(A10)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 11(3 q.-a /6-A.,. gallons per day. Calculated daily flow gallons.
Plan Date I Z!21 I o-a Number of sheets o rte- Revision Date
Title 124 seKrize- Zlesr ft H
Size of Septic Tank /500 �a/& Type of S.A.S. lnccact, Ckonb� e,-
Description of Soil 0 l c—z e- r c,(T r 40 Sall 10 5n ,�(Gin (9-FA 7 4
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement: !�
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss b16his h.
Signe l l^vl (,6� Date
Application Approved by 6 Date 4
-Z -00Z�7
Application Disapproved for the following reas s
Permit No. Date Issued
..;P
41
No. ';J'9 + r Fee/V Q
t THE COMMONWEALTH OF. MASSA HUSETTS Entered in computer:
/ PUBLIC HEAJ-/,TI- DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for biopool *p6tem Con6truction Permit
Application for a Permit to Construct CK Repair( )Upgrade( )Abandon( ) C?�Complete System ❑Individual Components
s
t Location Address or Lot No. I t q Ca p4, S"o.al—s le-e Owner's Name,Address and Tel.No.
% CO (•tJ
Assessor'sMap/Parcelj �•o• ��"c 2o�S r
'. V►��4W 38 9C.4 A4 Co 4v�t OZ(o3s J'
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
15*�121a., A Wi
C.t/V
?- t-3 Yt - $1 z Yvta S+ 01- V-vl i Le OZb S r N
Type of Building: �//
Dwelling No.of Bedrooms Fo u r Lot Size 201 6&3t sq.ft. Garbage Grinder(Ale)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow!Ie4 ham'' gallons per day. Calculated daily flow �� gallons.
Plan Date I Z 1241 A Number of sheets O ete- Revision Date
Title �2�4 Car,✓ $4N.a�DYzrS -septic Dsr'A-
Size of Septic Tank Type of S.A.S. �,cacll Cklcl `Ixn
Description of Soil t«c rc r 4-0 5010 105�
!{ Nature of Repairs or Alterations(Answer when applicable)
f
,p 1 3v o
Date last inspected: , vk
i Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmen . de and not to place the system in operation until a Certifi-
cate of has Compliance been iss b. this a th.
p ne �� INt�G..U"'" Date
Sig
# Application Approved by f4YDate �2_2�' w�
Application Disapproved for the following reasons
Permit No. 2 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
0,0
R that the On-site a Disposal System Constructed( 000)Re aired( )Upgraded( )
THIS IS TO CE �� p y P
Abandoned( )by ((S�
at Z G61%P C-A —G9 ha been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No`rl~ 7 dated I/?- 7- �
Installer Designer
The issuance of this pe 'is ll�e,construed as a guarantee that the syste I fun dZ) designe �(�
Date Inspector
No. Z
C U -7 — --------------------------Fee )00. i
p qq THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
"=igPogar 6e stem Construction•Permit
'. Permission is hereby grpnted to Construct(pair( )Up rade( ) ►pardon
System located at -
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construe ion must be completed within three years of the date of this
t % 2 6/
Date: Approved by
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o Leaching Area Requirements
Design Schedule ELEVATION
NIXO
AVE o0 4 BEDROOMS AT 110 GPD/BEDROOM = 440 GPD
TOP OF FOUNDATION 61.0
i FINISHED BASEMENT FLOOR 53.2
�P EAGLE �o FINISHED GARAGE FLOOR 60.0 ADDITIONAL 50% FOR GARBAGE DISPOSAL --NA--
POND SEWER INVERT AT FOUNDATION_ 57.2
SEWER INVERT INTO SEPTIC ANK 56.9 PERC RATE = _2- MIN. / INCH (CLASS 1 )
S �
SEWER INVERT OUT OF SEPTIC TANK 56.6 LTAR = 0.74 GPD/S.F.
S a 0 SEWER INVERT INTO DISTRIBUTION BOX 56.4
cn�'n \ _ MIN. LEACHING AREA OF S.A.S.
SEWER INVERT OUT OF DISTRIBUTION BOX 56.2
�0 `' SEWER INVERT INTO LEACHiPJi:, SYSTEM 56.0
LOCUS Z CAP' BOTTOM OF LEACHING TRENCH 54.0 440 GPD/ 0.74 GPD/
S.F. = 595 S.F. MIN.
�, tSiAti's GF WATER TABLE
PROPOSED SYSTEM : LEACHING GALLEYS
a
_ F 12' x 35' x 2' _ 608 SF
119�ti r
IS> �<v CB DH FND
X 1:9.6
OLD P T GENERAL NOTES :
S fl 57.3
PK/SEr ALL SYSTEM COMPONENTS SHALL BE INSTALLED 1N ACCORDANCE WITH
LOCUS MAP >>0.41 . TITLE V OF THE STATE SANITARY CODE DATED
N.T.S. u 159- F 59,7 x CP , MARCH 31, 1995 & ANY LOCAL RULES APPLICABLE.
5 .3
MAP 38 PARCEL 44 X ° •. ,... . .: ,.
.; �.. „ :• T ANY CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING
ZONE: RF & AP w WASHED STONE'.:,"- *-
ZONE:
t 8Y THE DESIGNING ENGINEER
SETBACKS: FRONT: 30 FEET � CB�D
SIDE: 15 FEET �' o ' , WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING, -
>: {�. N� p
REAR: 15 FEET ` '� "
NOTIFY THE ENGINEER & BOARD OF HEALTH AGENT
_ FOR INSPECTION.
0 35
PLAN OF LEACH CHAMBERS FOUNDATION ELEVATION MUST BE CHECKED WHEN COMPLETED.
D 1VE e x 5f ' X:X 60.0 -,." O�OSED R NO SCALE
ALL SANITARY DISPOSAL SYSTEM PIPING TO BE 4" PVC,
�• � � .1, ` /� 2 "� � � � ,� l+•"* EXCAVATE AND REPLACE ALL UNSUITABLE MATERIAL SURROUNDING
TP
o ( # SURROUNDING THE LEACHING FIELD FOR A DISTANCE OF 5', PER
N 310 CMR 15.255.
FINISHED
,/► ...�-'. -�. ��.,., Y � o \ \ \ \ `� \fir\TT\T7�'T\'� DATUM NGVD
0 10 ,. 1 -A o N ,� \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ ;�
W -1 / / / / COMPACTED FILL
0 1 N TP #1 / �i �, _ = 36 'MAX.- 12�f IN. //\ //\\/ OF UNDERGROUND UTILITIES ARE APPROXIMATE AND
2'- e PEAS70NE SHOULDNBE VERIFIED IN THE FIELD BY THE APPROPRIATE
X PROPO$ C7 w # 06� rn�� a 4 3/4" TO 1 1/2 UTILITY COMPANY PRIOR TO ANY CONSTRUCTION.
„ aa.
G6kRAG E C 0.1 �� 30.5 a O
DOUBLE
WASHED STONE
0, \ 4k
SECTION
MIN OR0 00'5 D BENCHMARK NO SCALE
HOUSE ` J5 9 ELEV = 56.8'
>� aJ•0 ti x '� .f x PK/SEf °
o' o' 40' 60' LEACH .CHAMBER DETAIL
SCALE 1"=20'
ALL PIPES TO BE SCHEDULE 40 P�,'�.
__ .. .X 60.7
JO
�OaS t4 ; tt c r r
IP/F D I CERTIFY THAT THE PROPOSED FOUNDATON } „ 14>
,n �I ,7 �'t=I Nora
o
COMPLIES WITH THE TOWN OF BARNSTABLE SIDELINE
AND SETBACK REQUIREMENTS AND IS NOT LOCATI:=D
\ WITHIN THE FLOOD P N.
DATE. 11 R.L.S. in� �
d' THIS PLAN IS NOT SE ON AN INSTRUMENT SURVEY AND
THE OFFSETS SHOULD NOT BE USED TO DETERMINE LOT LINES. ' oad
5 hda '
\ PREPARED FOR
\ I A
TITLE
BAXTER, NYE & HOLMGREN, INC.
FINISHED GRADE = 60.0
TYPICAL SYSTEM PROFILE P-9874 DATE 12/. /00
TOP of NOT TO SCALE
,A
I FOUNDATION = sr.o> ENGINEER: BOARD OF HEALTH: , c , INC.
STEVE WILSON DONNA MORAND1 Registered Professional
FINISHED GRADE OVER TANK = 59.01 Engineers and Land SL$2'Ve C7T'S
FINISHED GRADE OVER D. Box = 59.01 TEST PIT 1 TEST PIT 2 �'
FINISHED GRADE OVER LEACHING FACILITY = 59.Ot G.S.E. = 59.9' G.S.E. = 59.9' 812 Main Street, OSterville, MA 02655
8"MIN. r
3" (min-�
4" SCH. 40 PVC Phone- (5081 428-9131 Fax - (508)}428-3750
(TYPICAL) 4" SCED. 40 PVC FIRST 2' (TO BE LEVEL) _ 0 0 0 0 ` l ` J
s' (min.) 12" (min) Cover
PVC or -� OL2 min 36" (max) Cover 4„ 3"
10" Cl TEES GAS BAFFLE 6" SUMP .
FINISHED CONSTRUCT ACCESS 4" SCH. 40 PVC
BASEMENT MANHOLE OVER INLET 2"Layer 1/8 tol/2" E E
FLOOR = 53.2 TO TANK TO AT LEAST
Peastone
WITHIN 6" FINISH GRA �''� ' � ' •�''' � SANDY LOAM SANDY LOAM
. ... ,. LEACHING CHAMBERS
REINFORCED CONC.R 6" CRUSHED Slope = 0.005 min $„ 10 YR 3/2 7" 10 YR 5/2
STONE BA
FOOTING
• O • Oso
O • O O • • O
�• 4" PVC SCALE: AS NOTED DATE: 12/21/00
O O O • • • • O O O O � B g
O O O O O O O O O O O O SANDY LOAM SANDY LOAM ; REV. DATE: REMARKS
20" 10 YR 3/6 24„ 7,5 YR 5/8
y
BOTTOM ELEV. = 54,0' L�
1500 GALLON SEPTIC TANK DISTRIBUTION BOX 5' MIN C MEDIUM C MEDIUM
COARSE - SAND SAND DRAWING NUMBER
70 BE INSTALLED ON A LEVEL STABLE BASE TO BE INSTALLED ON A LEVEL STABLE BASE 132" iO YR 5/6 132" 10 YR 7/4
SEPTIC TANK 70 BE INSPECTED & CLEANED ANNUALLY 3 OUTLETS REQUIRED No Groundwater Observed At Elev. 48.9
CULTECO RECHARGER 330 NO WATER ENCOUNTERED
PERC @ 60" H:\2000\2000-97\SURVEY\worksht\200097septic.dwg_
RATE= - MIN/IN JOB - 2000-97
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