HomeMy WebLinkAbout0072 CLAMSHELL POINT LANE - Health i 2 C;layrishell r oii t Lane
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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d DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5 ` od's
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 72 Clamshell Point Lane
Cotuit MA
Owner's Name: Richard&Gloria Uber
Owner's Address: 271 Robert Road
Marlboro MA 01752
Date of Inspection: November 15,2006 Job# 06-309
Name of Inspector: PATRICK M.O'CONNELL
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Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779 � =I
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ^4� t►� i���
_X_ Passes
Conditionally Passes . G
Needs Further Evaluation by the Local Ap roving Authority _ P M I m
Fails
U O-C
Inspector's Signature: V, Date: 11/15/06 %� Ti���o.• '� ``�
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healtfi 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: leaching pit had no standing at time of inspection and has never been more than half
full.Tank is not in need of pumping at this time.
****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.
t
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria Uber
Date of Inspection: November 15,2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ 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 imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria Uber
Date of Inspection: November 15,2006
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
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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria Uber
Date of Inspection: November 15,2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
— —X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— _X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
— _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS,or�
cesspool
— _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
— _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
— _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
— _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
— _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
— _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
— _X_ 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 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.
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 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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria Uber
Date of Inspection: November 15,2006
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
g
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_X Were any of the system components pumped out in the previous two weeks?
— _X_ Has the system received normal flows in the previous two week period?
_ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ — Was the facility or dwelling inspected for signs of sewage back up?
_X _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X_ _ 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?
X_ .—
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
_ _X_ Existing information.For example,a plan at the Board of Health.
X_ _ 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)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria Uber
Date of Inspection: November 15,2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): unknown Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):N/A No design plans on file.
Number of current residents:0
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use:(yes or no):No
Water meter readings, if available(last 2 years usage(gpd)): Two years total: 71,000 gal.=97 gpd.
Sump pump(yes or no): No
Last date of occupancy: Weekend use
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,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: Tank pumped 8 years ago.
Source of information: • 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 DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
30 years.
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria Uber
Date of Inspection: November 15,2006
BUILDING SEWER:XX .(locate on site plan)
Depth below grade: 3'
Materials of construction:_cast iron _X_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:XX (locate on site plan)
Depth below grade: 3'
Material of construction:_X_concrete_metal fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions:8.5'long x 5.2'wide—1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:28"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: STICK WITH HINGE FLAP.
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 is not in need of uumnine at this time Tees are intact and clear,liquid level at bottom of outlet invert
GREASE TRAP: No (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 tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of.I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria Uber
Date of Inspection: November 15,2006
TIGHT or HOLDING TANK: No (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: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: No (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: No (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.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria Uber
Date of Inspection: November 15,2006
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X leaching pits,number: One 6x6 pit.
_leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
_innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): Leaching pit empty at time of inspection has never had more than 3'of standing water(50%of
original capacity).
CESSPOOLS: No (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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
I
• Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria Uber
Date of Inspection: November 15,2006
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.
Clamshell Point Ln
Water
Service
40
24
11
2
• Page 11 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Clamshell Point Lane,Cotuit
Owner: Richard&Gloria.Uber
Date of Inspection: November 15,2006
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 30 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:
_X_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:
Surface water at rear of property is approximately 30 feet lower than bottom of SAS.
TO OF BARNSTABLE N
LOCATION � V Jr
1� �ltl L n. SEWAGE#T,50At 01,
VILLAGE 6-1v ASSESSOR'S M/�AP&PARCEL Oo �6 O
NAME&PHONE NO. —��r;C L Q�0nAJ1 Lid,& n—i
SEPTIC TANK CAPACITY 1600 Q
LEACHING FACILITY:(type) '} (size) 1000
NO.OF BEDROOMS OWNER ckc.-,r'�'n
C)her
PERMIT DATE: CAL- 9 DATE: Jj l/S' GCS
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 360 feet of leaching facility) Feet
FURNISHED BY
C,: -.3hell Point Ln
Water
`
Service
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TROYY WILLIAMS L
SEPTIC INSPECTIONS Al
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Certified by MA Department of Environmental Protection 8) 385-137
19 Hummel Drive �t7ygy� 0 1g9R r..
South Dennis, MA 02660
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COMMONWEALTH OF MASSACHUSETT A F'
EXECUTIVE OFFICE OF ENVIRONMENTAL A GtS % OPY
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE HINTER STREET. BOSTON, MA 02108 617.292-5500
WILLIAM F.WELD TRUDY C07iE
Govemor
Secretan•
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr
PART A
CERTIFICATION
a Ci�� satii ,o;h4- � �. Co4vf+
Address of Owner:
Property Address:
Date of Inspection: I I/3 (If different) J , jy Y0"9 1, tv
Name of Inspector: Troy Williams r.a /3oX y� °�
1 am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000)
Company Name: Troy Williams Septic Inspections Co�� ; � N'lu
Mailing Address: _19 HUMMpl DriVp _ South OPnniS , MA 02660
Telephone Number: T5 O F 1_3 8 5-13 0 0S-
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_V1 Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date:
The System
yste Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, Or D:
AJ SYSTEM PASSES:
VYS I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES: IV 14
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.
Indicate yes, no, or not determined (Y, N,or ND). Describe basis of determination in all instances. If'not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(—i—d 04/25/91) Vaq. 1 or 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
72 Clatnshetl Point Lane,Cotuit,MA��EE��T IFICATION (continued)
Property Address: Judy Houghton
Owner: November 3, 1998
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES (continued) A1119
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
Pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: till',
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SKIS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 Clamshell Point Lane, Cotuit,MA
Owner: Judy Houghton
Date of Inspection: November 3, 1998
Dj SYSTEM FAILS: Al/1
You must indicate e-;,.er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an 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 1/? day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portiori of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 fro,rn a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: N//9
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 100 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
72 Clamshell Point Lane, Cotuit,NM
Property Address: Judy HOUghton
Owner: November 3, 1998
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes/ No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal-:x
flow rates during that period. Large volumes of water have not been introduced into the system recently or
/ as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
✓ _ All system components, excluding the Soil Absorption System, have been located on the site.
tL _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ The size and location of the Soil Absorption System on the site has been determined based on:
_✓ _ The facility owner (and occupants, if different from owner)were provided with information on the proper maintenance of
/ Sub-Surface Disposal System.
y Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance i
unacceptable) [15.302(3)(b)I s
(r.vi..d 04/25/911
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 Clamshell Point Lane, Cotuit,MA
Owner: Judy Houghton
Date of Inspection: November 3, 1998
RESIDENTIAL:
FLOW CONDITIONS
-
Design flow: Y/y0 e.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:0—a
Garbage grinder (yes or no):—?'6S
Laundry connected to system (yes or no): VES
Seasonal use (yes or no): Y r:-_ S
Water meter readings, if available (last two (2)year usage (gpd): 9 8= `/,oDy v 4//n�, a y _ /0 3,0 00 q i/o r
Sump Pump (yes or no):_IV6
Last date of occupancy: ,Su e u s c w +L
COMMERCIAUINDUSTRIAL.
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes orno)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if.available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
�✓ h I
System pumped as part of inspection: (yes or no)-/o
If yes, volume pumped: gallons
Reason for pumping:
TYPE F SYSTEM
Septic tan soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: s �x c Jt
Jar ✓ (.. S - L�
Sewage odors detected when arriving at the site: (yes or no)::�i
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 72 Clamshell Point Lane, Cotuit,MA
Owner: Judy Houghton
Date of Inspection: November 3, 1998
BUILDING SEWER: j(/�/a
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _ 40 PVC _ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade:_Y,S h U s r S e ' z w r y
Material of construction: [concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:_ S K 9 / G ' /o o a �u I/0
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle: 2
Scum thickness: AlaIVC
Distance from top of scum to top of outlet tee or baffle:)U6 5
Distance from bottom of scum to bottom of outlet tee or baffle: A/6 S w,
How dimensions were determined: ry e- ,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or b foes, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) C'_o ., ._a- � a 4-1- 4S ��� , ✓ ti /�f
wo li o.-o'l /Vu I � .rs v7� Ste.✓ c �iYc, / //
GREASE TRAP:—S/I/9
(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 tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(r.vi ud 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
72 Clamshell Point Lane, Cotuit,MA
Property Address:Owner. Judy Houghton Date of Inspection: November 3, 1998
TIGHT OR HOLDING TANK:AAA (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: /11/-a
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)_
PUMP CHAMBER: NI/9
(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.)
(rwl•�d 0�/ZS ic
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 72 Clamshell Point Lane,Cotuit,MA
Owner: Judy Houghton
Date of Inspection:November 3, 1998
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number.
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
, 4-
r U h
/ U
a .. d
I XJ/�tJ b �t.._.n, s /h �i.L /i� S '>� i i✓� ✓�v� t.. �-- f � rti. L o �
t- O
CESSPOOLS: /J �/9
(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(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(r.vi—d 04/25/97) P.q• a of 10 .
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 72 Clamshell Point Lane,Cotuit,MA
Owner: Judy Houghton
Date of Inspection: November 3, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
c�p
trww-F-w �
�S./Ulr
-4-
(revi..d 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 72 Clamshell Point Lane,Cotuit,MA
Owner: Judy Houghton
Date of Inspection: November 3, 1998
Depth to Groundwater _ Feet adjusted high groundwater level
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
/Observation of Site (Abutting property, observation hole, basement sump etc.)
V Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
41
� �w� � 07 Is Le—C— y ; .s ho
THE COMMONWEALTH OF MASSACHUSE'rTS
BOARD OF HEALTH
Aphration for Difyviial Works Ton-4trur#ion Vautit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
............_-......�..•-•-_•... .. ...................................••-zwr •..............--•--------•---••-•----.....__ ..........--------•--•-•.........•-••••...
Coca' n-Address -76-70 or No.
/ C.� /(finer...................................................... d .....
Installer Address b p1�Q
Type of Building Size Lot__!_-`.✓_!-./__-(-----......Sq. feet
Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder (ir
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Pa Other fixtures ......................................................
W Design Flow................:sr _...._._.......___gallons per person per day. Total daily flow----------- en-
................................gallons.
WSeptic TankLLiquid capacity/' -gallons Length---------------- Width---------------- Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.__ ._ Total leaching area....................sq. ft.
Seepage Pit No.......1........... Diameter.,/ _*ZDepth �c ile _. Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( ) d/�- �C - - Z 0~-7,1-
�' Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' r - r
O Description of So'1._ `t G it
dx
W _ -R-------- •4-�. �� d� ���"
VNature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issue d oar f health.
�7 7S1 d_ .. ••. ----
/' Date
Application Approved BY... L1 - - 7 r1 �
Date
Application Disapproved for the following reasons:----••-•------------•••••----------------•-•--•----••----•-----•-•------------------...-------•---•-•----..-•---
-•--.....---••----•----•---•.............................••-------......-----•----......-----------------•-••-••--•••-•.....•-•-••---•------••-•-----•-.....--••-•...............•--...................
Date
PermitNo......................................................... Issued....../.1:--...�- ........
Date
I_---- — -------------- ------------------------------------------------------------------ --------------------- y
No..... .. '2 .,�. Fnf ..................
THE COMMONWEALTH OF MASSACHUSETTS
�- BOARD OF HEALTH
�!
. xs '
Appliration for:f3ispoiiai Works Tonotrur#io n ramit
Application is hereby made for a Permit to Construct ( . ) or Repair ( ) an-Individual Sewage Disposal
System at:
5.............. .. ........ _...... ......... ....._... ---- ........ ,A..........._.............7�Y.............................................................
Location-Address 'q or Lot No. -
AAM ... ------------------------------740144 X& :r . �, ►
Owner Ad ress
r
a r. i _s -A Re.,4,faV-�-------------------
Installer Address
d Type of Building Size Lot..I�Qt.7,64 t.....Sq. feet
~� Dwelling—No. of Bedrooms......... ..............................Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P- Other fixtures ----------- ---------------------------..................
W Design Flow...................AQ.---------------.-gallons per person per day.; Total daily flow __,_____2- dl_p..................gallons.
WSeptic Tank-Liquid capacity/4Wgallons Length...............:'Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width--_ --_-________- Total Length..._..._....__._.__ Total leaching area....................sq. ft.
Seepage Pit No......./........... Diameter.-/4CM ►Depth ,11d4le)�" . Total leaching area.............•...sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 44�. /CA . 2 40-141"
Percolation Test Results Performed by................................................................ Date..................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth.to ground water...............
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
....r.---
..................... ,.... ... , /� ...
Descri Description of So' ___ �" - .� I ,] /�s!
4-- -
W ------- --------------------�r /�-- ' r � `/U Nature of Repairs or Alterations—Answer when applicable...------ --------- - ---_--- ..............................................
-------------------------------•----•--•----•-••----................................................................................................•.........................................=......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article YI of the State.Sanitary Code— The undersigned further agrees not to place the system in
' operation until a Certificate of Compliance has bee issuedWv the board of heal h.
igned-- ••••-• Z;r -
Date
Application Approved By.----- ••. —------------------------
-
Application Disapproved for the following reasons---- ....................-/------------••--------------------.,.:.:---•--..:_...................--••------•-------
--....---•-------------------•-----_--••-----•••-•••-------•--••--•-•-•••---•--••-----------------••--....••-•-•-••--•-•-------•-------•---•-••••--------------•.......................................
e / to
Permit No. ..............°------.... Issued-•-- l.. .......................................
Date
THE COMMONWEALTH OF MASSACHUSETTS 4
`. BOARD OF HEALTH
.0... .�! ,.t.....OF....................... ...... .... ...... ..�:��;;��;.� . . �.,
fit
wrtifira of
THI TO CER F ha th Individual Sewage Disposal System constructed ( 4.@r0fepaired ( ).
r
by -- . ............................. :..
r. .... ` ............
f * �a;:,cAS,has been installed in accordance with the provisions of Ar 'cle I o e a anitary Ccribed in the
application for;Disposal osal Works Construction Permit No. dated------ -- =--------- ----- ..........
PP P �.5 ---------- ,r .
THE ISSUANCE OF THIS CERTIFICATE SHALL N Tl(¢ ORISTRUED A A G �6?�AT THE
SYSTEM 'WILL FUNCTION ,SATISFACTORY. .
DATE........ .�._._ ......7... Ins or. --- ..........._ .........
-
THE COMMONWEALTH OF;MASSACHUSETTS
BOARD OF HEALTH
OF........... ................................................
A �,• x
4
NJ .............. -
- `
Disposal I"or T U Wit rprutit
Permissi(kn i' eby anted.... �.... *� -----------------•---------•------.....-••-..............................
to CXV
.( tar . e ir•( ) an nd' Sewa)-C)
e Disposal System
at N �a •• .....
L _... __ .. .. -•-_... ,� y.._....�_ -.
as shown on the application for Disp.'osal Works Construction—Pe it N ... Dated.._. .;/ �r 73 ------
:� -
DATE----- 1'J
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ..
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LOC.&.TION / SEW 64E PERMIT UO. .
It�IST�LLER�S- 1JQ_ NlE -ADDRESS
ev
-BUILDER 5- -Q A . E ADDRESS -
-- --DD►TE-P.,E R Nl1T--1 SSUED-�-�-�-7 J�__ ____ _
COt%AP-Ll &l,.ACE ISSUED.:
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it
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4 :.� `. rh'l�,4: �'•♦ :�,y�,�,§r. h ',a V
� ,O. - _ •a - .� •'] •9... a ,, «� #'..'1,:i �i.: #, �'r.. y 4' '.^ 'k �'tr #` t rk �, �`�Ry`t �°r .'�wf _ - F`b•,
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/1�1� �Clamshell! Point
. •' Lot •l�i � Lame�'_ �ti`.' ;:, .. �a, •� - _ ^
' HMV Ir riiRt �WVv .. 'y, 'C 'i.s , �f #7. S y i € •5 ,
Mr Michael':E. Jones:, ,:♦; 4 T # .� ,� xJr: ; _
' •C21ae1 .S.pJon®s'x1s8C>clate allAlC r; t ,•S' '� • My:. +. �" }, �� *.. �Sr �e E.. �1 r
[�yyt� s ,Locust Street
,a Fa�,mouth� Massachusetts _
� e �4 ..{, �t � , Y _+. 1 • 1 �+•'- i .s 'S'L •SJ«- » •4 , .♦♦ # �' -f"d�� < f • '
Dear; Mr,. Jones: F ;"^� 17
t �ya
# t Q request for va'
�ne to inatal nare .812t `feetr'.a var3
ngpti l n nleachi sconh ona fy .aroved, ,7
. ,
Frior"Ito Board- of,HAalth'4a ?p pvaX .r� <yvu .;lau lc�3A perm ,'A a •bY 4 ' a
perco•lafiion" test,_must bey�bsery .Eby a;Health n pector`-at your T
+ . ,Proposed -sewag® aiteo After,-4pk(;,' o' rcol tidh • es �<<
z well-.must be .in_ stalled a'nd wsi���r ,�e�te� at COunt)r; Labor t' .a>� ' `
application : e a rov - a oryy;begore
ed,f In •addition�< we,will ;refer your,plan _to y
a the Con�ervaiionpCommittee for' its approval , ♦ 2
;.
The ,ro,`. sedy � � ` ' -
`P po sewage.0installattoil ,must .,conform t4 gall Father rutles
and;regulations 'of,'the tBdinstable 'and y Mate. Health', ep jay pn s '
r
t e
Robert, L. Chi. Cis Chairm_
au
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�>b +� ! 4 •': x.:•r� .ia,t y :?q ea i� ..� r _ .rg >x 17 a - HAZard, i,: i',J.• ''� t'
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r't� �' .4 ..+. t \A 4. !may ;� �.;�' �•7 v:,;:lL i ar._t r,' p'}. . g. : .•oV
�£ .9 S � '1r .Y% t " h 4_,• � �A. C .e Y 1°'E r .• r� a �, d 4T ti rr #.:, ♦ A •� + �
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MiCHAEL E. JONES ASSOCIATES, INC.
DESIGNER - BUILDER
38 LOCUST STREET
FALMOUTH. MASS. 02540
August 14, 1974
Board of Health
Town of Barnstable
Hyannis, Mass .
Gentlemen:
On behalf of the owner, Brian H. Rowe, of Lot 10,
C lamshell Point Lane, Cotuit Coves , Cotuit, I am requesting
a variance of the 150 ft. minimum distance provision
between the well and leaching pit.
I am enclosing a site plan showing the proposed
locations of the house, septic system and well; the locations
of adjoining wells; a proposed seper. ation between well and
leaching pit of 120ft; and a. distance between the leaching
pit and mean high water. of 110 ft.
The size of the lot is 20, 760 sp. ft. Mr. Rowe has
owned the property since December of 1967 and does not own
any contiguous property or any other property in the town.
The proposed house would be at a, si-ibsta.ntia.l elevation
( approximately 20 ft. or. more ) above mean high water.
Upon approval of the variancer. eouested above, a soil
test and well sample will be taken according to the usual
procedure.
I thank you for your consideration in this matter.
Very truly yours,
MICHAEL E. JONES ASSOCIATES, INC . '
li
Michael E. Jones
AUG 14 1974
TOkIVIN OF ,-.ARNSTABLE
;:CnX-',D of HEALTH
Per..../�..........,......,...
ram, r�
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Nile
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BARNSTA13LE, i
y MASS.
August 19, 1974
Mr. Childst Chairman
Barnstable Board of Health
Town Hall
Hyannis, MA.02601
RE: Lot #109 Clamshell Point Lane, Cotuit, MA.
Dear Mr. Childs:
At your request the Conservation Commission has viewed Lot #109 Clam-
shell Point Lane, Cotuit and has determined that the placement of the
proposed septic system is far enough away from the water edge so that
no hearing before our Commission under Chapter 1319 Section 40 will
be necessary.
Sincerely,
Nestor A. Aalto
Chairman
AMW/mre
�.
AUG 2a 1 1�17-j