HomeMy WebLinkAbout0026 CHARLOTTE AVENUE - Health f° 26 Charlotte Avenue
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ar 29 2016 17:50 Jim The Inspector Man 5085349919 page 1
■■ Commonwealth of Massachusetts
Title 5 Official Inspection Form
A - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name 3>
information is _
required forevery Cotuit . ✓ MA 02635 3-28-16 . �+
page. Cityrrown State . Zip Code Date of Inspection W
1a '
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 A. General Information
filling
the computer, ``\\��o��H OFrMgsS
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o
use only the tab 1. Inspector: �A� • '' ti"'-
key to move your = JAM ES `•tp
cursor-do not James D.SearS = t
use the return Name of Inspector
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key. Capewide Enterprises, LLC
Company Name ,��� ��. ... . • 'Q
153 Commercial Street "'�n��,�,illa\0`�•\
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to.Sectlon 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3-28-16
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system'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 conditlons 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.
15ins•3113 Ttlle 5 Official Inspection Form:Subsdrface Sewage Disposal System•Page 1 of 17
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Mar 29 2016 17:50 Jim The Inspector Man 5085349919 page 2
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Charlotte Ave.
Property Address.
Leif Norenberg
Owner Owner's Name
information is
required for every Cotuit MA 02635 3-28-16
page. Cityfrown 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 system is a 1500 Gal. H-20 Tank. H-20 D Box and four chambers.
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,staternents. 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•3113 - Title 5 Official Inspection Form.Subsurface.sewage Disposal System•Page 2 of 17
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Mar 29 2016 17:50 Jim The Inspector Man 5085349919 page 3
ZtX Commonwealth of Massachusetts f
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16
page. City/Town 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 ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe($). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO (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
16.303(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 ram:Subsurface Sewage Disposal System•Page 3 of 17
IMar 29 2016 17:50 Jim The Inspector Man 5085349919 page 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owners Name
information is required for every Cotuit MA 02635 3-28-16
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 is less than 6" below invert or available volume is less
than Y day flow 4 F4(*(1v6:
t5ina•3/13 Title 5 Officia Inspection Form:Subsurface Sewage Oisposal System•Page 4 of 17
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Mar 29 2016 17:50 Jim The Inspector Man 5085349919 page 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owners Name
information is:
required for every COtUit MA 02535 3-28-16
page. Cityrrown Stale Zip Code Date of Inspection
B. Certification (cost.)
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 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water,supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ 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.
t5inns•3113 Title 5 Official hspecton Form:Subsurface Sewage Disposal System•Page 5 of 17
Mar 29 2016 17:50 Jim The Inspector Man 5085349919 page 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16
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 CM 16,302(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): 33.0
tSins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
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Mar 29 2016 17:50 Jim The Inspector Man 5085349919 page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is Cotuit MA 02635 3-28-16
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal. H -20 Tank, H-20 D Box and infiltrators.
Number of current residents: 0
f
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use?. ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 2014-25,000 's
g ( y g (gP ))' 2015-19,000 Gal's
Detail:
Sump pump? ❑ Yes ® No
- Last date of occupancy: NA
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Mar 29 2016 17:50 Jim The Inspector Man 50853499113 page 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16
page. Citylrown 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: 2006/2011
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):
15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Mar 29 2016 17:50 Jim The Inspector Man 5085349919 page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16
page. City/Town State Zip Code Dale of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
1996 Permit#96- 153.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1811
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other (explain).
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate] ❑ Yes ❑ No
Dimensions:
1500 Gal.Precast H-20
1
Sludge depth:
51na•3i13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Mar 29 2016 17:50 Jim The Inspector Man 5085349919 page 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16 .
page, Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Oil
Scum thickness
8
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-TapeSludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 8"below grade wl center and outlet cover steel at grade. Inlet cover
under black top drive. In and out let tee's. No sign of leakage or over loading,
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-X13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 10 of 17
Mar 29 2016 17:51 Jim The Inspector Man 5085349919 page 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
26.Charlotte Ave.
Property Address
Leif Norenberq
Owner . Owner's Name
Information is
rkquired for every Cotuit MA 02635 3-28-16
page. City/Town 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:
f
❑ 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•3113 TNIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page i t of 17
Mar 29 2016 17:51 Jim The Inspector Man 5085349919 page 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,•' 26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is
required for every Cotuit MA 02635 3-28-16
page. City/rown 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 df solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is H-20-26" below grade w/steel cover at grade in black top drive. Box is clean and solid
w/one line out. No sign of over loading or solid carry over.
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:
15ins-3113 Tide 5 Official inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Mar 29 2016 17:51 Jim The Inspector Man 5085349919 page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16
page. 04rFown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four infiltrators 9"x31'W" 3'stone. Chambers at 30" below grade. Camera out and
ck D Box clean and dry. No sign of over loading -holding water or solid carry over.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth -top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 13 of 17
Mar 29 2016 17:51 Jim The Inspector Man 5085349919 page 14
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16
page. City[Town 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 Insaection Form:Subsurface Sewage Disposal System Page 14 of 17
Mar 29 2016 17:51 Jim The Inspector Man 5085349919 page 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16
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
l'j?oNr
0
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4
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t5ins N13. Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Mar 29 2016 17:51 Jim The Inspector Man 5085349919 page 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16
page.. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
No
1011
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: 3-7-96
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:
T.H, on Design plan 3-7-96 no G.W. at 10'. Bottom of chamber's at 4' below grade. Bottom of
chamber's at 6 above T.H. Depth.
}
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Dlspas21 System•Page 16 or 17
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Mar. 29 2016 17:52 Jim The Inspector Man 5085349919 page 17
r o
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
26 Charlotte Ave.
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 3-28-16
page. Cityrrown 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
1
® System Information— Estimated depth to high groundwater
r
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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1
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t5ins•3113 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 117
7
Commonwealth of Massachusetts m1 1 d f
,,:.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Charlotte Ave
Property Address
Leif Norenberg
Owner owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information r�
on the computer, (� ``���jH OF MgsS C
use only the tab 1. Inspector.
key to move your
cursor-do not James D.Sears
= ; JAMES ';m'==_
use the return Name of Inspector
Y
ke CapewideEnterprises,LLC �* '• ` *�
�'• o 'Q-
Company Name �I f Q:N`:
153 Commercial Street ��4��511 fNSP,EG```����
Company Address
Mashpee MA 02649
Cltylrown State Zip Code
508-477-8877 S 1623
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 ink ction.'T4ejnspeAion
was performed based on my training and experience in the proper function and r lal tenancej#on si
sewage disposal systems. 1 am a DEP approved system inspector pursuant ection 15 340
Title 5(310 CMR 15.000).The system: _
® Passes ❑ Conditionally Passes ❑ Fail
l X.-
❑ Needs Further Evaluation by the Local Approving Authority
Q 00
6-14-14
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
-Ze— -71e/e
t5ins•3/13 Tide 5 Official Inspection Form:Subsufface Sewage Disposal System•Page 1 of 17
3 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cost.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
I
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
26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. ,Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
MW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. City/Town 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 can
pW is less than 6" below invert or available volume is less
than 1/Z day flow , .&�C"ll/yC
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
26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
m Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M y 26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
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
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
.� 26 Charlotte Ave
Property Address
Leif Norenberg
Owner owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal. H-20 tank. H-20 D Box and infiltrators.
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 2012-73,000Gals
g ( y g (gp )) 2013-69,000Gal's
Detail
Sump pump? ❑ Yes Z No
Last date of occupancy: Present
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•3/13 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
26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is Cotuit MA 02635 6-6-14
required for every j
page. Citylrown 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: 2006/2011
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•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
y 26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
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:
1996 Permit#96- 153
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
18"
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.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 8"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
i
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 Gal.H-20 Precast.
Sludge depth: 2„
t5ins•3/13 Title 5 Official Inspection Forth: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
26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. City/Town 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
28"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
1 7„
How were dimensions determined? asbuilt tape sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 8" below grade w/center and outlet cover steel at grade.Inlet
cover under black top drive. In and outlet tee's. No sign of leakage or over loading. Note: Maint pump
after inspection.
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 26 Charlotte Ave
Property Address
Leif Norenberg
Owner owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. City[Town 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
4 M , 26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is H-20-25" below grade w/steel cover at grade in black top drive. Box is clean and solid
w/one line out. No sign of over loading or solid carry over.
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:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four infiltrators 9"x31"x2" 3'stone. Chambers at 30" below grade. Camera out
and ck. D Box,clean and dry. No sign of over loading,holding water or solid carry over.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
.:Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•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
26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
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 y< 26 Charlotte Ave
Property Address
Leif Norenberg
Owner owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. Citylrown 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
� 0
13 -1 = i8
1� �-- ;3�
.23 /A a
p-3 = 33�
O t
O
3
t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth thigh ground water: 10"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: 3-7-96
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:
T.H.on design plan 3.7.96 no G.W. at 10'. Bottom of chambers at 4' below grade. Bottom of chamber
at-6'above T.H. depth.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
t- ►� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. � 26 Charlotte Ave
Property Address
Leif Norenberg
Owner Owner's Name
information is required for every Cotuit MA 02635 6-6-14
page. Cityrrown 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
i
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of'Massachusetts
Executive Office ofEnvirorimcntal Affairs
Department of Environmental Protection
TITLE 5
OFFICUL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSI EE TS
SUuSURFACE SEWAGE D SPOSAL liTEM TN\i F.CTi:iZ F(? 1
PART A
CERTIFICATION RECEIVED
Prol,,erty Address: 26 Qhiidotte Avenue
Cotuii, MA 02635 MAY 14 2002
Or:'ncr's�anic,': Jciu.ifcr and Stc,,jh,'n 1'1'cbb.' TOWN OF BARNSTABLE
c� Philfiks Roadt HEALTH DEPT.
�)Gi%tl�r'S C Clr?SS: `� LCII
KingSton; MA O'r/364
Date of ln�pcctic;rl: 013/2 f/O2
NuaIrIP of 1rlst)ect.^,r: Hi.•arn,lones
Conlpiiny `vane: :T C & it
\tailing Add.Tess: P. O. Box 339
East.Bridzewitter. XIA ti2333
MAP
"Telephone dumber: (508) 3 i 8-331 ti `� PARCEL ' �9
CER T IFICn 'ION STATEMENT LOT
i r r rtiti that i haer pr:rSona.nv m6l;c r_.tCcl the scwa.gc dishosa.i sytitc:m at. this aoClrras a.nrl tnairhr inform, '(_in naiortcc.i
big o%,, is Lfui:, at.Curati•ittid c•rirtlplidi:as 01'Lli0 Lithe Ot'Llii iiisuciaioii. Tlic frtSpevLion was lit iiilt'iiti it 11-18SCd Oti iiiy
Lrainin "a!id experlence.in Lille. pioper fun(.6on and niainLe.nati e of on silt'.sewage dispOsai viLetili. I ani a DEF
approved system inspector pursuant to Section 15.340 of Title 5 (310 C I IP,15.000). The system:
X Pass et III
Condlitionallv Passes
Needs Further Evaivation by the Local ApproNir!g Authorlih.,
Fa-1Is
s�
Inspector's Sn ature: V- '� Date: 03/21/02
T1-a,clrm inSpff or 511a!1 sut?mil:i rnti�:rii'l!7i5 in5i?l'rLion rcporl Ln Lhr :nprrl,,:ing auLtiOril�; "Roar�i of Hcalth or
DER within 30 days of completing this inspection. if The system is a shared systern or has a nest;,-n flow of MUCH')
q*1)d or rc::�tcr, ih< inslx:r for anci ownur span stjnmit thc_report to the alipropnatc:rr vmil orfir,c of the
DEEP. Tltc Origin"MI ,I-ioulcl lit:setiL Lo Llic syst(itii ilwlir r aticl i uhiis scnL Lo ilir.buyer, if appliiitbic. iuiil Lli(l ac)c)r iving
autilOriN.
Notes and Comments:
****This report only describes conditions at the time of inspection and up-der the conditions of use
at that time. This inspection does not address how the system will perform_in the future under the
saxne or different conditions of use.
Page 1 of 122
f
OFFICIAL INSPECTION FORM e NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE vVAGE DISPOSAL SYSTEM ItiSPECTION FOR XI
f,1 h'l' A
CERTIFICATION,(continued)
Property Address: 26 Charlotte Avenue
Goluit, MA 02635
Owner's Nar ne: 1crinifcr and Stephen 1-\''cbbv
Date of Inspection: 03/21/09 r
I>nsrectioni Summary. Check A,B, C, D or E (ALWAYS S complete all of Section D;
A. System Passes:
lave not. ou1l i+ illy LI vi`ilidii )n whtidh incricatcs that aT,yt, the f aidure ci nil d,scr;beU
in .i 10 CMR 1 ?_, ll3 or In :110 CMR 15.3114 exist. Any failure, criteria not evaluated are
indicated below.
B. System Conditionally Passes:
t)r . or more system comp;nent:i as de.scribe_d in the t`�(nditliJilai �i�:s„ ..'ction need to
be rc (placed or 12pajred. Thr Vstcrll. ufion 1'.fi111pI(tUun of dhe, refilat e.n-iena or rcpalr, as a
approved by the Board of Health, will piss.
li,ncwer vHs no or not.lrtrrmineCl In the for the ff)lif.)ti:'T P.ti StdieTl?r'il ts. If"not
de..termined" please explain.
l_ septic tank
! O(1 !* 1. 1 / ; '
1'h•` �� `•ins:i�rectal Ludt OVi:r w yi:ar�OICi Or the sCptiC tank i�Yhi:tl'iCr metal Or nCitt is
.;VU WI'all4' i.nls(`und, CXhlbii.s SUl15t_intn! lfililtratiOn.(-)I, i_ink " illirr is IIIIHIltl(ftit. SiSACIR
[-1'1}} pass inspection if the existing tank is ,P}�lacecl +']L11 a comply' se, tapir�c
approved by the Board of Health. 7 1
*A IT etal septic ta__1 will pass Tns—pecdon if it lti structurally sound, not leaniit1 and Ti a Cf.'.riiiilr-lte
Of Compliance indicating that.the tank is less than 20 years old if available.
D _XfJl_tlt!):
0I,,str%,at;on Cif sewage bad:l:fl r`r brriik tint tw lillrh st"ft water level in the distribution
}}(iX due t(_i }ir(�nf'n (jr ob-itru tY_.i }il ji('.I$1 iir due to a br(ihe.n, settled or uneven itistr ib,ution
box. System-will pass Tnsnection if,,with approval of Board of Health):
Brol-rn riitiplsl iirr-' rr'.l_il':C'.e:I
U UJLL UItloll IS rC nlovi;tt
t t i_ I
t)i�iJ`il:n_itioii {illx is li_vC:l�•Ci or T`i:fil;�Ci:i{
NT) (exp}ain),•
Thf} s strin required pumping more than 4 tirn a yei?r due to a broken or olbstructed i
pip_(s). he systcrn Yv1111 pass ilispection fl(-w'ith approval ol'Board of ficalth:
liroken pip p;s are rr.pla ced
011"'strtiltiOn is remu'ved
ND fi_xplaln):
Pale 2 of 1 l
i
®FFICLAUL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SI LSUP�FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (co-tinue )
Property Address: 26 Charlotte Avenue
Cowii„ MA 02635
Qw-ner's Name: -hnni.fcr and St,,Ij1.cri 1Vcbbv
Rate of Inspection: 03/21/C2
C. Further Evaluation is Required by the Board of health:
�.'ondit;ons.txi—b:'1?:.'�? reClUlre furtl?Y e:; �U:i[l:)? Iy)�:it?e 1Sf):IrC� !)? �1f."iltl? in (_)rcitr to
d e*ermme ?t the svistcn. ?:i tali?n`to protect I)t?1)iiC.health, satety or the environment.
1.1 System svi11 pass unless the 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, safer and the en-vironment:
Cesspool ?)r pri-� is:':'itilin �)t_1 fY-tt of s 1 face:rater
Ccssi)ool or 1)rivV is Vvithin 50 ii_Ct o1 a 1)orticlin"-7 VCg tated wetland oI'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 vsttni 1?as a st-0c tank an(1 soil) abs,.)rl)t?(),i system (\a\l and the SAS ?,NV;t1??n I0i'
1CCt of a surfdcc water supply oI' tribLitat-t' to a surl1-icc -vva1,C1'su1)P1V.
The system has a septic tangy: and SAS and th- StiS is within a Zone 1. o a pt11)l ic,water
SUl)j)iV.
The e cte rn has a stptic tanl.- and `AS ant the SAS is ?thin �ih_l teetota Private water
u1)i)1v -v,:C11.
TI?Y 4e:ct m 1?:'`a`t.1)tiC' t in}; and SAS and the SAYS l• less than !00 ftet t)Ut 50 f--t or
u mire frorni a 1)r ivz-ite Water Vdeil. used to Cieterminc distance:
**Tli;Q-stem 1)::sst•s, itthe w-eill ::7attr aria lysi� 1)t'rforMed t a T1 Y,P;'.t'.I"t?tIY.CJ
for('.o,17i7rlii r<^i(aI'rl<i a.nci volatile ^ ;arils.i;on.—,j)oUnIds, lndli.a es that the vJe"l ?: tree Iron:
wflution from that facilliv and the I)rescncc Cif ammonia nitroicn and nitr;.itc n1tro&-rcn Is
. . 1 . , , .. 1 .._
rilu�il iii or lcss tl?;;ii? :-i li1'ill?, liiiivii hii tl?ai i)u?rt f.Ilil.lrt7 i'.i'ltrTi�l:i?"r tl?vurrri . n t'ulil of
the analysis must nP aitached to this f_'orm.
3.) 0tIner:
Page ? OF 1
OFFICIAL INSPECTION FOi3.P.�--NOT FOR VOLUNTARY ASSFSSINM N s S
SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM
NART A
CERTIFICATION (Ccnlinued)
Property Address: 26 Charlotte Avenue
Cf)(i_)it, MA 02615
Owner 3s Nai e: knnij--cr and Stei2lam Wcbb:-
Bate of I nspection: 0. /21/02
D. Systeni Failure Criteria (applicable to all systems):
You must indi ate `v—s" or "n;)" to each of the follo.ving for,-,',! inspection...
YE.S Nil
_N BaC;n)liC, uli Cif ticivayC into faciliiy vi �ysti-nl i'C)i111)Citieill CTt1C U:) iii`crlUaClr�l or
clogt;eCI SA
SS or Cesst3ool.
:1 Discharg—(]r pondino,of effluent.to the surface of the around or surface Nvaters
Cltle ir, an t,i'rtl 1_tClcd or 61-Tc l SA'S or lrssllrlrIl,
=1 StatiC.litl.uid love? in the Clistributionn box above outict in'vcrt due to an ovcr-
loadcd r`_clogged SAS or cesspool.
..1 1 t,_.. _ G" 1.. .1.. .._ .'i 1.. ..1 __. 1
.♦ ,dlltalii i rl)Tl 17) i'r1Sixxn la Ih�� u,z,Tl C) uruft4 ini'cri of�T.-V�Tlti, ilr.Guliltnr. iS Icss
than Vz dai iloV .
x RCYitiircc l)Urnping i one than 4 limes iti thc.. last y:'ar NO Clue to dol—tiCd ,01-
j� obstructed pipes). \umber of times pumped:
:\ Am pc ton i --the SA). ctesipot)l or prlq is ?jelo-,v hig?i `roun"i water elevation.
x Any p om.on cl Cessp,,)ni or privy is Nvithin 100 feet of a surface.Water supply or
'I �
tt'ilit,t icy to a stir`{aur 11a1Cr 11npIy,
K Any iiortTon o± a cessii:loI i)t'Firl`v y 1, hin a.Zone. ? i)f a pu bli C.iveli.
A ni-nort' i.f:.eeQ-1-ol or prim:iq i..fit?)in )1.)feet Of,t l?rl:" t! Water cUl)ph'i:' )!.
Any portion of a cesspool or prii:-"is less than 100 feet but treater than o feet
r,.. , rl 1 , . ...._. ,
,tutil i.lit`iVate i�--airs Sll?)l)li`ii'rn ii lt)) nil::u'l c�)i:i})le iwa.ter ilil:i,.11fi'�il)ii.ly-sls.
('This system passes if the well water analysis, performed at a DEP
certifed lab-oratory, for colifoit m bacteria and volatile Organic
compounds indicates that the well is free from pollution fro>r,;i that
facility and the presence of ammonia. nitrogen and nitrate nitrogen is
equal to or Hess than a ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form."
' "is% T mint, or m)r ft ff:� s i '3LPe C ae
failure C.rit?ria exist as described in 10 C`MR 1.).303, therefore the systern fails.
i {li_ SvSl.i Tii ii�tn%i'j{iilu{Cl ei)t)t:dl_i t?)i_ FiWi'C) of Hi_a-10i to (loortnit ,I aj will I:)(-
-Necessary ,,()._o correct the failure.
P-g- 4 of 12
OFFICIAL INSPECTION FORM m NOT FOR VOLUNTARY ASSESSMENTS
SULSU I'ACE SELVAGE DISPOSAL SYSTEM IINSPECTION I'OP.M
PART A
CERTIFICATION (continued)
Property Address: 26 Chi IrIott-e A,,^ue
Cotl_lit, Mid 02615
l!wner';Name: i,• n, "uncl „hmi ,,`v'cbby�,.ii��if Ste,,
]Cate of inspection: 03/21/02
E. Largo Systems:
To he considered a large system the system must serve a facility with a design#lo:v
of 10,000 gpd to 15,000 gpu.
Y oii must indicate either cct,F, n it"no„ to each o the fbilowing:
I he Iollov mL,criteria apWv to laruc systems in aC{C{ition to the critcria abovc)
YES NO
The s,stem is.,ithin ?i() feet of a surface drinl:inc,eater sul plti".
is v ithin 200 I%t t cd'a lnIxii_8.i'y ti, n sm'I'rc(duinKilif'
The systen: is located in a nitrogen sensitive area,Interim I'Vellhead Protection
tuna-Pr TA; or a mapped Zone II of a public sur1iiy %will.
II}:lu ha.;e nswered to anv Cll es.t1C)n In Seetl:Tn ��, t!le.sNsttm is consic{ereC1 tilsnifica.nt
+l + 1 f l T T t
ulrei,..� or answered "yes"' ]n �et'tlon t',above, the large sVSt.eT7T has Fll,e_.G. The C%`b�"leT'C%r, -1)er�.,.,r Of any
i � I , ,a .l , ,. shah' h.
. lar,Ti: s�stem i:CirisiC,eteCt a siiTr,i,li:�int t ,rear iiriCter�C etilJn�',Clr,ai eC{ LiilCter�i:i:tiiiri L st alt u(i�,rae{c the
t'1 t . �
sVsTr.T"li in �li'i:()rii�i.rii'r.tilili :r r ti (;l(R 1.5. 04. The si'strTii i,wilra'tiillrl.Ti(:l (.ililiz,i'.t iilr allhl'i)lirlatr 1"rcrii)n�i
office of the i)q),irtnient.
Pa-e r, of I
OFFICIAL INSPECTION FORM m NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Pr1RT h
CHECKLIST
Property Address: 26 Char1otte. Avenue
Cowit, MA 02.6
Ou-ter'§Name: -1crinifu and Stcp)hcn 1,,Vcaav
Date of Inspection: 0 3/2i/02
7 f)f,:•.t; if tl1e t�)l1! ::'ln r have 1)een l ) e �r , t Cl at �a. r o :c �: f w
C ) c:tr._. I )u mas, lr. is e ` ;e „ o. "r. ,' T�e h f t.)e f_)lio lns:
YES NO
1 Purnped in'LOrmation was provide.d by the owner.. occupant or Board of'Health.
Lti rare an !lf,the `:<tem {)lii r)`�n ran tti rl i eCl r iit i t , r i two weeks?
= = i • _ rump . o n he ,) evioas to ee s'
x Has the system receiVed normal flows in die previous two week,period'
X Have large plumes of Nvater been introduced to the system recently or as part
of this, inspccGon'.
(If flity were not
availabtc, note as N/A)
Was. thv fac:ll;�'or Clc.;rl}insr lnspectecl for signs of SeS,,q It 1_);<<:,1;up?
�. 1, t 1' t A ,_cat �
e � `r'eri:all SV4tcT'il cpriipOnci,i�;c'xCliiGin�'tli? SAS, IU�.<,�ed on ji`t?:
Were the septic..tank manholes uncovereCl, opened, and the interior of the. tank
inspectcd for the Condition of thi- hat}}cs or tl_cS, Inatcria}Ot COIISU'L[Ctioii, diMCII-
sif;ns, Ci!-'.ptli Of hqudd, ckpith Ol S1Ud'C and ckj)th (;I •,cum?
x Was the facllltv ownel-(ancl occupants )f C.lifierent from owner) prC)ide(i with
information on tliC l)roper mainti:nanci_ ol. ub-surtacc sewage disposal JVJtcrosJ
1 The size and location of the Soil!Absorption System (SAS) on the site has
been determined based on:
X Existing ir4brniation. For example, a plan at the BoarCl of Htalfth.
Determined in the field. (If any of the failure criteria related to Part C is,at issue,
approximation of distance is IinaCrepta)iiP; jllJ 1IR lJ.3302 Ji.oii
Pa-e 6 ur 1?
OFFICIAL INSPECTION FORM e NOT FOR VOLUNTARY ASSESS I ENTS
)VL lU11 1,l 1L)LV Y/Lll Tll.,Ll 71)ll�Y/ZL)17)1L Vl 1'Y 711 t,%.A 1`Y 1�\11\1'1
IlA Il'1• 4"
r/%ry I qL,
AIL-1
S�iIV
.. AAA«oom •Ih 1�hvrlr.ttu L1�/umir�
%A Mlill._ N111 IILI 1:).)
%�I No o -nnlft•r anti `trrlhl•n 1%l-bl'n.-
TIl_a_ _1`T______ nrl /1)1 /n()
1J i1.LC Ul 111,UCl:LlU1l'. klJ/ 41/lIL
11;_1
R!;U IW.IV i SAS.
N mli..r �h �f hurl•- ..._ Al n'r ` \'..mhu.•r.♦•F. 1 i�.�t..nit• '�
T%UC'Tf \T 11.._._L..-__-,1 91n /-rT.iT) I^ r)no X__ 1_. I I n 1 u 1•I- -1 oon 1
1Jl'.Olk-TIN Ill/4V U<1JCU on J II1 k-livl l\ Ii.LIIJ !Il)1.�'A<Li11�lIC. 1 Ill ��lll r tt ul Ijr r Vllllil, JJl-) =pu
a
_�Il lT .._ nT r _rr
_tnt rPC1rIPniC_ - -
i is la`:i ra:4iiii Yir h. F I % rr')\• . . . . . . . . . . . . . . . . . . . . . . . . . . i��'�
`,u a a tila lGlti� ilrill i!yi,l a_ir a_I!.
Ts oul �.I st 1pm l.ir sriwhur.systrill I VCs or no': . . . . . . . . . . . . . . . . . . . . . . . . . :VI1
1..alrnr1r'v CvCir•rn InC nr'rlr•rl Ivr'C nr•nni•
�i;u:ii:iiui u..a; t,i•i.,. i.ii iiJj. �I',•.
is
YV a.trr Illrlr!if: l(Il ll�s. 11 va,i la.l nr, IIi1S1.L yrdI u",1 !r. IPI)1.I II. . . . . . . . . . . . . . . . . . . . . :V11
_limn nmmn (v,P nr nn! ivn
W1111..iii
�:�iIVIM N.K�:S41.%1 NIil I`%K14S.
''I'.ma r.+aotnhl,nhmcr.r•
T\ r ) n n_ .._ ) n 1 r) na rn 1- nnn\.
11C.11�11 111 UC.l1Lt11 lli:j4\' ifbaJCU (Jh ,11t Y._Vll\ 1.J:L l 1,1 . . . . . . . . . . . . . . . . . . . . . . .
1`AC1C nT flPCltTn Tli Ii.t,'ICP;i tC%nPYC(lnC%Crl Ti-, tic.): _ - -
no):
inclivurini [taut- I ninlnu iin1C nrPCPnT IVPC or nni
i\Ur;_`::r::<i:r•v r:��.L C::.S'C..:.r, .•C: .' .Fl:. r.:C ..) Q\;i•lr•m !a,- -,;'r;r-
YY 111.1 1111,1�.1 11 1.1.11 r12;J 11 AY 11111J)l-.
T \
I.a,\I_ (1_iiv I)1 O1_riqua.rio, (1\r: . . . -
1 11hrr•lfir�cr�n hC 1:
i-N.Iv M.K AT IVHnK iVI L!I Irvr%
1 r%YSIVr jV j-.I iK�i`
J(/Ur(,C of inif'Or111A.111/n: . . . . . . . ki'yyi1Cr 111111COLICU 11riJ 110l 1/CC11 l/llllir)(t.11 1i111.(' ccinstrl.ciCl.l
... . r• ,
VV'-1C C\i CtPm nllm pee. ;1C part nt inP ...... ilnn 1\%PC nr nr_I,: • • •, • . • - . . . . . ..
ivn
l low V%`as 1iu21,11111V illlllH)Cll 11C1('r111111C11. . . . . . .
h PaCnn for TIumT11ng: . . . . . . .
1.----I----Z,
I1p(T? -/ nt i /
SUBS U 1:.1/vil l'1:\.IAG-11: 111C1)/\CAI SYS'1.1:\:1 t\�l'1)I:/"1.1O\\' t.•I)U\:1
V1\1'fl\aL.)li V'Y \TL lJl.)1\/.7CY1�r.71.)11i1V1 L'\.711i\.,11 /:\ 1\/1\1V1
rART is
S Y-S 1 N.IVI IVF 0K_NL'A 1 IT iCGfl Lin lu`rt)
n..,iiit- MA 0,ncor
�lh>ror"j Name: Irn)i kr and Stephan \'Vr JU-7
DT_._ _O Tom____ /1V /O1 /Ili) .
a.LC V6 inspel:L ow.. VJ/L 1 J VG
TYPE 13H S V\1 M.IVI
Septic tan-! ui:,tr ibu iom.
7111#
Overflow ti!'PCcn(ll it
JIIc11CU l41tC111 ;•\C'l VI Ill l) Of yrl.. G1.(.lcll_11 p1 t=vIl/Ul 111.l.prl"l.11/il records,. if any",
mno�:atiur/ralrernatic*e ternnolot)ti- vrtar•n a copy or t_nr current operation
------'----� -' _----'-------�- "`.7 .,.V�.,.KA...Y.. Ar^m cciam n..;nai1 V--- -r---••----
and a". aintf=n`a i ontu;t !+ Ma r. taincri t
Tight 111111(nttallt it copy
VL lll,_ LJJL approval
F1f)f Irl)XI(1l a.lr :i s)�r 111 :ill ('()((11 I(1(Irflls. hair IflSlalirl l III ht11 R1.'fl`I :{I111 SI IllrCr f 11 I(1111('IIIaI I()fl`.
System installed In 1997 ivnen building constructed as per SIC bunt
ii,i.- ri,- ,1.-di .h a Ih.- :V? i�i.
uYiri ua;i'a Y.YY:A.I wln.aa uiriv iia,�; at un., .v u,: _ ,
KI III.I IIt G SM.VVE I1nr•att on city plan)
Depth. holm,.-rn-nrlc•
Maicrial 111 l,1/11.11ructil n: 'Ca.SL ilon 40 1% u t/.wCr ICXl.1lah-Il:
a
1)ictan,�A 4rnm Y -a to• -n+ar o Y�L. n+i C) li»o•
�.._ , ,_ 1 IiY�,Y ,_ Yr K,.�.. oi'a`:i)J,y �/, u�.uVu ..,.... . . . . . . . . .
Cornil tints (on i ondiLion Qf ii-iini . venting, evidence of leakage, vw):
SE.N'�IC. A-3 AR 1500 gal craw on Aro-
111811,'.
\..-..L. I...I,.-.-..-....J... 1 7
L\.Utll Ul1V VV L;1 clUt.. 1
ri[irrltlass i rifvl_iriyu_rtl_
i ilhrr Irvrpiak:
1 1'
II �_)nl< Is (rll_I_ilI_ 11s1 aul" _ . . . _
Ic a,rr-• confirmed by �._..cr,,ific.a Cam.: Compliance 5T or nr-11• Orr fa.adi a copy ill ccr.;�:c..../.`1
..tip - Compliance t, � .. .../. 1. ..:..N. .. .- .
' 1111111.11 J1VL1J. 57 x ✓ A J
,�nllls�'r oroln: 0"
Ilismnce !turn top or sludge In bo`lrom -YI -l:Lie: .'Y•or b.a..:..r 34"
fill
VL Utll tl lll.11111_.?J. lr
.r�• r• r• 1 r 1 1 rY l l tt
171\[_i(I(_f' Ir(1(il II)1)(11 \(_I-IIII 111 I1f)11(Iffl OI (Illllr( Iry llr lxvll■t_: 1'-+
Distance ance bum imnom nt cr•nm by Yet ttom rit ontlr•t tr•r/ar battle-•• i4"
How 1'Y I_1f. Ulll ll l_11J1V11J U,_ll.l llllili-U. llli_151.L1e11
- tAl Ii IIII II:fill((-)I-[ 1111If I11Wg fm1 Il Ililll:f llla.l.l!)111. I1111:1 ?i(Ill lllll,lla 11:1: or Ilalill' l'f 111(11111)11s7 wI I`I II;LII ta.l II111:}/dI V.
Velum IP As AC related to outlet invert? evidence QT leakage, etc):
1"
1 Anl- a NN pn`m s SLruct'Irali'`olund and does not appear to (`al.•.I
ANome X nt 1%
ge V Vl 1�
::i--n-C .A..:..INSP�.�..y._O FOIR INO-0 il%K ASSESS iy
..�.,. a.,.,..v.,a.�•a
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Il A I1'1' -.
r.�r.L1 � ....
�Y` ��lV�tTV M� ■KAAR'OTl 1-8 IV Ir^nnl mllr�rll
roperti,AA-1-oo• 91F %�I',•.r ri:ittc+ L]lrvnlls+
vpa.a a�
��::rroff'j Nµm o: ��'nnit`'r anll .\irrin`•)� 1.`\AW1[r
Date Vl 11l,UCl:Lillil: 1 3/ L 1 i lIL
G Ka H-:A C.W Au: ,`Inl-are on sire ni:t.ni
\,...�L. I.,.1,.... J,..
1-. Cw1/ Ul.1VVY L'L dtc:
Y.r 1 I %r .r I
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i irhor ir•.rii•ai ,'I
I\:
L 1111111JIV LIJ.
•l(:IJ rfl I IIII'.Krirss:
Loll: it n rJ:c,-.,: i0 hn.inm -h: :,—lir'i got,r;i'
I\:..I........ 1 1 -"- ...., - hOU01... -I ....l i- .. . h..11l...
L 1.lilllll_ Ll Vlll IJV IIVlll 111 �l_Ulll lrJ IJVIIIJ/ll Vl VUl Ll ll�l�VI IJ lllll�.
Tl 1-1
1)a.ir III Iasi nnrnninu'
r - r
LIVllll ll lllJVJ 1LJlllE� l Il ll11_l ill!l J-l LI lI l._.lI l.{_OL IIJ-.Ql11l1t-, I
ill Ul,lUI 711111,-ZL lIv,
llllUlU lr\rll as dill ll ll/ l)L.l ilrl 111\f'1t. viil�ul,C'111 lri:lN0,12,1=, rll,.I.
1 � L r
1G_14 1 nr_M_l 1/1.1/I IVA_1.41V 1Lr. ;T;Ink rmist he 11n T7 ped IT.Ti Me-nT inSIIPCTtnn i!,li r(-:3TP on Sire 111 iW!
Ll,l/Lll 1/cll/VV Elalul,.
1.1 1 t v Y.I 1
t;r_Irrr_rr_ic nir_i_iI rr Lit_r'ul;4'�,; i'ni\'r_�rr�rlCriC
1 lth c,r(s,vr,l•,tn�l+
L 11IB-L1J1V11J.
- II
i:anar iiv �';Innns
1�Ir,�nrn Ilr.h a;• Ir•,Ilnrw rl o,:
A 1,. .. _.. 1..,... .. _.,.1. -
l11Q1111 IJLI_Jllll IVIJ Vl 11V;.
Ht;irrrl it-ve-l: `• mll:ir'rrl Irl 44(1f 1�'np-ilrrlrr"IVrti Ilf" fll ll:
1 1GIr� nl lacl nnm Winn•• �
1:viulilciii5 tt_viiuliiviiSVl aldiia niiu llvai 51v'iiCuCS, Cii;.�:
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IJq(iP 1 / nT 1%
No. FEE
THE COMMONWEALTH OP MASSACHUSETTS
` 4a/VSrAi?eE MASSACHUSETTS
(Xppliration for �t$ G$ttl 5 steGt CnGuetrurtion F jermit
Application is hereby made for a Permit to Construct(�(,) or Repair( ) an On-site Sewage Disposal System at:
Location Address or Lot No. Q/b ®(90-®Od Owner's Name,Address and Tel.No, 6�� 0 9
� �®
�(a ClAodor 't, �2 Co'Tvaf Qe�l�� T�sf
9//iL C0+0 i 1 P,G, &)x yv2 14AoFA 44,4 O 23 8
Insta is ame,Address,and Tel. Designer's Name,Address and Tel.No.
A)m/iYo'r d WeBRY Caloc
Type of Buil -
Dwelling No. of Bedrooms Garbage Grinder( )
Other Type of Building No. per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33 U gallons per day. Calculated daily flow y� gallons.
Plan Date Number o sheets Revision Date
Title S'
Description of Soil Oq �'����
HOSSAM
Nature of Repairs or Alterations(Answer !9
mW
JVGINEER MUST SUPERVISE No. 2851 1 a
P TI R NG
Date last inspected: 1,
Agreement:
The undersigned ag ee to ensure the constr ion and maintenance of the aforedescribed on-site sewage disposal
system in accordance with th r ion f Tit 5 of t e nvironmental Code and not to place the system in operation until a
Certificate of Compliance has a issue by is Boa d f ea
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. I �' �3 Date Issued
rfi.� -^ "r • !� � .. .` 7a �+ g�,�,.. w�.` A%a, r � _ • �.;mow
OV
No. J r, t. ~ ' FEE+ C--
- HT E COMMONWEALTH OF MASSACHUSETTS -
=, MASSACHUSETTS �+ .
jjjzt:>ra i n for is II$ 1 stem Construction Fierntit
Application is hereby made for a Permit to Construct(k) or Repair( ),a'n On-site Sewage Disposal System at:
Location Address or Lot No. 01b—G(;0_C)0d Owner's Name,Address and Tel.No.
_ Co To ij Qeaj,� TVLJ¢ sbs,a�oo
P N c CJf L) P v« Qc,�< yu2 c.
lnsta is ame,Address,and Tel. Designer's Name,Address and Tel.No.
UAu ral o-f q UJOBBy .CU Zr7c
Cow►
Type of Buil
Dwelling No. of Bedrooms J Garbage Grinder( )
Other Type of Building No. per Persons Showers( ) Cafeteria
Other Fixtures
Design Flow 3 U gallons per day. Calculated,'daily flow yC/ gallons.
flan Date 2 Number of sheets Revision Date
Description of Soil OQ o
® OSS
p
"Nature-of Repairs or Alterations(Answer when applicable) rJ No. 28573 1
~ E 1
Date last inspected:
Agreement:
The undersigned a ee to ensure the constr tion and maintenance of the aforedescribei on-site sewage disposal
system in accordance with th pr v to of Ti e 5 of t environmental Code and-nofto place the system in operation until a
Certificate of Compliance ha b issue by t is Bo rd of ea _ 'l
t
Signed Date
Application Approved by` Date' 2
Application Disapproved for the following reasons
Permit No,/ L, �' ��-� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
t2/a:ZA .[= MASSACHUSETTS
- Certificate of Grayltance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed 00 or repaired/replaced ( ) on
by for
at G[ ' ODD C vo i QI/k11e Q n has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a dated
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE � __ � � Inspector
f � .
;��., -- /� {, THE COMMONWEALTH OF MASSACBESI G ENGINEER MUST SUPER
No. �i+ � l..S A g I,TM 13 LL= , CERI
MASSAI' I NG
CT
is osal '16ptem Tonstrnct
Permission is hereby granted to 1
to construct ).or,re air( )an On-site Sewage System Itcated at 4,tz� nib—096 r_hCf 4_ /,C_ 7?
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.
►�aw
All construction must be completed within three years of the date below. AM&MtIIPERVl,S
- DATE Approved byAIC iG
A,FORM 1255 Rev.3/95 A.M.SULKIN CO.-BOSTON,MA ,' t % `-^� I v,`••LT
((. J�- �TOWN OF BARNSTABLE
4
LOCATION !N �1+ � ��` Q A SEWAGE # Aa1
VILLAGE 0-f 4 • ASSESSOR'S MAP &LOT IN 90
INSTALLER'S NAME&PHONE NO. T n e v e COr4 _ i-1-7 • 5 S 5 0 7 O 0
SEPTIC TANK CAPACITY 1500
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER J e n-e v e COW- 5 fe b"I We b b u
PERMTTDATE: d- `�7 COMPLIANCE DATE: 2 72
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility n 0 Wct-JV<`Feet
Private Water Supply Well and Leaching Facility (If any wells exist r
on site or within 200 feet of leaching facility) wont Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) D300A Feet
Furnished by
F_ �:%5fi. �cf
Owe n7
L00n% I
,A
ae5e ve
Area-
in 'f9�e,�CbZ
1O
L_
VAUTRINOT & WEBBY CO. INC.
CIVIL ENGINEERS
REGISTERED LAND SURVEYORS
Alan C.Vautrinot Jr.,R.L.S. 180 County Road/Rt.106
Joseph E.Webby Jr.,R.L.S. Plympton,Massachusetts 02367
Hossam M.Shemais,P.E. Telephone(617)585-6355
Fax Call First(617)585-5942
TOWN OF BARNSTABLE
HEALTH DIVISION
367 MAIN STREET
HYANNIS , MASS. , 02601 - March 11, 1997
REF: INSTALLATION OF SEWAGE DISPOSAL SYSTEM
AT MAP 018, LOT 090, PINE ROAD,
COTUIT
Dear Board;
This letter is to certify that the referenced system installed by
Jeneve Corp " has been constructed in accordance with the plans
as approved by the Town Of Barnstable Department Of Health, Safety,
& Environmental. Services .
w
Enclosed please find the accompanying "AS-BUILT" plan which
Includes the necessary tie dimensions .
Respectfully;
Vautrinot & Webby Co. , Inc.
6�o
. C . TOWN OF BARNSTABLE
LOCATION L.Ut "10 Pi,-i e Pd f Choi, u f fe ,Ave SEWAGE #
VILLAGE cif"u i f ASSESSOR'S MAP & LOT 1 y 0
INSTALLER'S NAME&PHONE NO. J- /-)eve CO,4 J`�S 0700
SEPTIC.TANK CAPACITY 1 S U u !2 a1(p ,—i
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS-
BUILD ER OR OWNER J C n e VC
PERMTTDATE: 7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility n 0 W` Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 1J612,r; Feet
Edge of Wetland and Leaching Facility(If any wetlands exist �O1�) Feet
within 300 feet of leaching facility)
Furnished by
u
J
, u
. C . TOWN OF BARNSTABLE
LOCATION LUf rlO Pi e 9J f C hU; Jo Or Av P SEWAGE# 26
VILLAGE 01-2 1 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. J('/-)c v e Col . (,1-7 - 5 S 5 0 7 O C)
SEPTIC.TANK CAPACITY 15 U y
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS J
BUILDER OR OWNER J e n e v e CUrp S f e p hQ-� 02 e b b u
PERMIT DATE: CQMPLIANCE DATE: — �• — 7
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility n 0 Wq'}p r Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) �JUr t; Feet_
Edge of Wetland and Leacting Facility(If any wetlands exist within 300 feet of leaching facility) _ (J1y Feet
Furnished by
r I 0 i7�
V1
U7-
,C
--------------
I
--
-" .�. � (0) Septic tanks shall be instaliod level and true tode tra on a level stable base that has been
�e._..._.. - "Ix' iJ mechanically compacted and on to which six inches of crushed now has been placed to
a / - »meveh WdlIng. If the septic tank is placed in fill,proper oampaction is required L�Q t.►!7/I r V ! NCH W/
to ensure stability and to prevent �tanks hall have a minimum cover of nine THE HIGH CAAACITY INRU RNOR00"BER
inches
W •At least*sine 20 inch msnholm with readily remov"impermeable covers of durable RECAST SEPT/C TANK 2o , No Scale
/Ivor 7o ScALE/ I500
,� mucrial shall be provided. Access pacts shall be placed at the oa�a mad over each inlet and f GALLON
g If ; X a` t;� Wet and outlet tea shall be made aooetsibre ntal NPJ*, the manhole " be placed as notes: t0 the '1 3„
for inspection and ,
maiaeamna by pit Precast coaaeto a cquivaknt watadsht raw'(with steps where I - ' 4 _ It
with never:over the modest to wntltia six
Tr-_l-'�,.j o�wish for sysoerrt 3 mIn I /2�� i'/ll/R
{ (N C � -- designs in etcess of 1.000 Vd. For sysa designs of 1,Spd air less,at 1�one amass - ------ _-- �
'/ ease
125
I�f
k pat shall be accessible within six Inches of final Made. Manholes brought to final grade .M 3 ^ ► �
` { shall be secured to prevent=%authorized arras.
(8) Septic tanks shall be accessible for inspection and maintenaam-No structures shall be ( 1b• 3" WASHED
located directly upon or above the septic tank access locations which interfere with / /
r� TANS`/$ 7t7/Z" W
performance,scats inspvtitsn.pumping,or repair.
LOCUS PLAN / Li V�/ �,:, (� Wet and outlet has shall be of art-'iron.Schedule 40 pVC.of art-in-plmco concrete.
!/ ;,
WAS
and shall extend a rrniaisrsarh of six inches about the flow line of the teak and be on - — /0 -C' -- - rx STONE•3/4"m/I/2" SItaNE 3/4"7D I/2 i�
SCALE /" �,_ ✓i/ c G the caner line of the septic auk located directly under the clean-out manhole. ` �r
Cross-sectional flow bMes shall not be used as substitutes for.inlet or outlet _ l 13 '
4 F r tees. 1---
IL
C rI J W Manufactumrs of septic tanks shall impler w mt a quality controVquality assurance — /0,-6 _ -_ 3 r —+•� 34
program in conformity with An M standard C 1227-93. Tanks shall be embossed with a seal i .?t
stating that this ASTM standard has been met NOTE /F THE LIQUID DEPTH OF THE SEPTIC TANK /S 5FEE7,
THE OUTLET TEE SHALL EXTEND 19 BELOW THE FLOW L INE
/ !VnTE /) a! I PIPING SHALL BE Sch. 40 PVC
%r 2J IT IS THE YE-PCIVSIBILITY OF THE INSTALLER TC VEK/FY THAT
THE WA SHEO STONE IS CL EAN AND `.,'EE (1- FINES.
.- —
ti SECTION THRU SYSTEM
"S. C t- (NC"- To SCALE)
0 -.._ _ GENERA L NO TES
�, � � � ---�,•, ^, ,3< FG =3c�,v (3) 20 M,H.COVERS TO W/TH/N
6" OF FINISH VRAD£ FG = 3 T,
_ 6 ; 0 ALL CON-'TRUCTIOV 1 J CJNFORMTO TIT[ E 5 0f THE
1� 1C,�
/ - _,// a /;-� =- - =/ a u/ /'/_ /7 ( MASSACHUSETTS STATE ENVIf,'ONMENT:JL :DUE; AND THE
., Sch.4o , ,a BOARD OFHE,4LTH REQU/REMENTSFORTHE TOWNOF____--.
'Or Scb. 2) NO i ERMANENTSTRU..TURE- MAYBE- ,.QYVSrRUCMD OVER
r- THE l00% EXPANS/ON AREA.
DIST BOX - �
---" I INFILTRATOR ) Tt/E DESIGN OF THIS SYSTEM DOES NOT PERMIT THE
m uSE OF GARBAGE DISPOSAL UN/TS.
SEPT/C TANK 1 "
4) CONF/RMATION OF CONSTRUCTION I ACCORDANCE W/TH THIS
° i 3 J < WASHED �
�_ STONE PLAN LS REOUIRED, THIS OFFICE AND THE LOCAL-BOAR!' OF
}~' _ + � �`�� -- - HEALTH SHALL BE NOTIFIEC PRIOR TO BACKFILLING
/M n0/ - '?J{ T H L S SYSTEM.
5) SEPT/C Tti NKS SHOULDHE INSPECTED AND CLEANED 4NNUA
U) ',REASE TRAPS SHOUL D BE/N,�PECTEO MONTHLY AND SHALL
HE CL EANED WHEN THE L E VEL OF GREASE I S 2�"/o OF THE
EFFECTIVE DEPTH OF THE TRAP OR AT LEA.S•T' EVERY
J tt t/ THREE MONTHS.
PROFOSED FLOW LINE GRADES AS BUILT GRADES
--.- ..__...__.._.._....,. _._.. IN v T FouNCA rl ON
INV LNTO SEPTIC T4NK J�'=� 0
INV OUT OF SE PTIC TANK 1-, 9) ALL ONSUITABLEMATER/AL FOUND, OR INVERT OF Dr, T
INV INTO DIST' BOX r PIPES ARE A50VE OR /N THE TOP AND OR SUB SOIL.
r INV OUT OF GIST E-{OX ALL TOF SOIL,SUB SOIL, AN_ UNS-?/TABLE MATtR/AL TO
NV INTO lNF/L TPA HE AIEMOVEF TO EL EV N Efi SOIL L O GS
� -
9
' •-`~---.s _ OT TD M '7F //VEIL TRATOR / A
._/z __ ___ AND FOR DISTANCE OF FEET /N ALL
,' . 1 `i DIRECTIONS FROM LEACHING SYSTEM. THEN REPLACED
,_.. a �' ... �.f ► •'� BOTTOM OF STONE
� _ �, :�, { W/TH CLEAN SAND FREE OF SILTS, AND DEBRIS, ANDWATER TABLE I� ,:=
,
MF� TINE 3/J C,t'R l.` %�S (3)
INSPECTION_ SCHEDULE_
l I°• � r �� �a==, �' I) AFTEFr EXCAVATION OF THE TOP SOIL, SUB SOIL, A/VD
�> SOIL LOGS '. ,..
OR THEUNSGlTABLE MATERIAL, BUT PRIOR TO
T. P / T. P THE PLACEMENT OF THE FILL.
a 7 e I,O S.S 2) AFTEH PLACEMENT UFTHE !LEAN FILL BUT PRIOR
•�`' '
.', _
/ f i.� A TO THE INSTALL OF THE SYSTEM
/(� .
-. _ �, - Yn / j'r 'r ' :� A A 3 FIN,GL INSPECT/ON ,
/ ._-_ , t ( yy� ti ( FOn' �S B(il(_, CER T lF/CAT/O
f , ; ) BOH RD OF HEALTH. J
` 4 ,' „ $ .. , y.,.. "• ` y , l F TO THEL-L
' of ^N
w
PEMBROKE ONLY
A ZABEL MUL T I- PURPOSE FIL TER TEE MODEL A/00 OR
EQUAL , SHALL BE INSTALLED ON THE OUTLET OF
IlePERCOL 4TION RATE OF M/NU TES / INCH ALL SEPTIC TANKS.
LJ , \ \ /✓ /.-. PRESENT DURING TESTS ON --
,.• .
/ \ t,, _,. i _ DESIGNING ENaNEERY pj WAmrSia so lL E vA L uA TOR _.
t ---
�., THE s smWS, T' -- --- --- --- - - -- --- NOTE:
DESIGN c, TER/A THERE ARE NC SURFACE WATER SJFPLY OR
f�EDR00M DWELLING Al GRAVEL PACKEG WELLS W/TN/.N 400 ; NO
J/0 G PB.D _ ` 'Q G.PD TUBULAR PUBLIC WELLS W/ THIN 250', NO
BENCH MARK ,� = PFi/6'ATE �nTc.yL E rrEL� s w,/TH/N I50 ; of
G - O ; z SF (RE�UIRED) THE PROPOSED SAN/TA,RY SYSTEM EXCEPT
w• LEACHING TRENCH
-_-�L.,iC- '_ �. F AS SHOWN.
- / WALLA AREA
n V 1 BOT TOM AREA
rOrAL DAILY J -- - - TOTAL AREA CAPACITY= I GALLONS
SF SUPFLIFO)
GNING ENGINEER MUST SUPERVISE
c - AL.LAT N�CERTIFY IN WRITING SA NI TA RY SYSTEM IN , , '
BALLED IN STRICT C5� �"
'C' ,;0RDN=10 PLAN. 1, J , v =�U }' 1 U 1 t �,<J -fir C
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