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Commonwealth of Massachusetts 3
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11
10 Cotuit Bay Drive
Property Address
Andrea LaCava rX
Owner Owner's Name
information is +/
required for every Cotuit Ma. 02635 12/21/2017 '�"
`page. City/Town State • Zip Code Date of Inspe'ion
Inspection results must be submitted on this form. Inspection forms may not be iltered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
use the return I
key. Name of Inspector
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Cape Septic Inspections
Company Name
624 Old Barnstable Road
Company Address
Mash pee Ma.
City/Town State Zip Code
9
ode
508-280-3356 S13938
Telephone Number License Number
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B. Certification
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I certify that I have personally inspected the sewage disposal system at this address an 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 mainter ance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Sect,on 15.340 of
Title 5(310 CMR 15.000). The system: !
® Passes ❑ Conditionally Passes ❑. Fails
❑ Needs Further Evaluation by the Local Approving Authority
t
eae:a:��— 12/22/2017
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving uthority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a clesign flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report t the appropriate
regional office of the DEP. The original should be sent to the system owner and co ies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the ,.conditions of use
at that time.This inspection does not address how the system will perform in'the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Dis 3osal System•Page 1 of 17 'IC
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Commonwealth of Massachusetts
v. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner s Name
information is
required for every Cotuit Ma. 02635 12/21/20171
page. City/Town State Zip Code Date of Inspe 6 ion
B. Certification (cont.) ,
Inspection Summary: Check A,B,C,D or E/always complete all of Section D !
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A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria c escribed
in 310 CMR 15.303 or in 310 CMR 15.
304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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This-3 bedroom home has a H-10 1500 gallon septic tank feeding a precast leaching pit. At the time
of the inspection the leaching was em and there were no visible signs of past hydraulic failure.
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B) System Conditionally Passes: t
❑ One or more system components as described in the"Conditional Pass"sectioj need to be
replaced or repaired. The system, upon completion of the replacement or repal;, 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. Sy tem 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 ifla Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
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t5ins.doc-rev.6/16 i
Title 5 Official Inspection Form:Subsurface Sewage Dis`osal System•Page 2 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is
required for every COtUIt Ma. 02635 12/21/2017i
page. City/Town State Zip Code Date of Ins'pec ion
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of ealth approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
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❑ Observation of sewage backup or break out or high static water level in the dist ibution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distributioli box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Expl in below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Expl iin below):
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❑ The system required pumping more than 4 times a year due to broken or obstft�cted pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Expl 'in below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Expl ,in below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in ordei to determine if
the system is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance witii 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will prod mt public health,
safety and the environment:
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❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or, salt marsh
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Dit osal System•Page 3 of 17
V
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is required for every Cotuit Ma. 02635 12/21/2017 page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, f any)
determines that the system is functioning in a manner that protects the p blic 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' ublic water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a pt,vate water
supply well. j
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 5(1 feet or
more from a private water supply well".
Method used to determine distance:
4
"*This system passes if the well water analysis, performed at a DEP certified labor'tory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrat .nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of he analysis must
be attached to this form.
3. Other:
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D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
0 ® Backup of sewage into facility or system component due to o erloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground r surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert du; to an overloaded
or clogged SAS or cesspool i
❑ ® Liquid depth in cesspool is less than 6" below invert or availakile volume is less
than '/2 day flow
t5ins.doc•rev.6/16
Title 5 Official Inspection Forth:Subsurface Sewage Di posal System•Page 4 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form {
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is required for every Cotuit Ma. 02635 12/21/2017
page. Cityrrown State Zip Code Date of Inspe ,ion
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 grounh 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 publ'o well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a privat 'water supply well.
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❑ ® Any portion of a cesspool or privy is less than 100 feet but gr ater than 50 feet
from a private water supply well with no acceptable water qu ;lity analysis. [This
system passes if the well water analysis, performed at a EP certified
laboratory,for fecal coliform bacteria indicates absent a['d the presence
of ammonia nitrogen and nitrate nitrogen is equal to or If ss than 5 ppm,
provided that no other failure criteria are triggered. A col y of the analysis
and chain of custody must be attached to this form.] i
❑ ® The system is a cesspool serving a facility with a design flow Df 2000gpd-
10,000gpd.
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❑ ® 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 8ystem fails. The
system owner should contact the Board of Health to determin what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a fa ility 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 supp y
❑ ❑ the system is within 200 feet of a tributary to a surface drinki 'g water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim WE llhead Protection
Area—IWPA)or a mapped Zone II of a public water supply m:ell
If you have answered"yes"to any question in Section E the system is considered , significant threat,
or answered"yes" in Section D above the large system has failed. The owner or o erator of any large
system considered a significant threat under Section E or failed under Section D s'all upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact th ' appropriate
regional office of the Department.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sawage Di sposai System•Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is required for every Cotuit Ma. 02635 12/21/2017'
page. City/Town State Zip Code Date of Inspe ion
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each `f the following:
Yes No
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® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previoi s two weeks?
❑ ® Has the system received normal flows in the previous two wee'k period?
❑ ® Have large volumes of water been introduced to the system re' ently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined?(If ey were not
available note as N/A) i
® ❑ 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 sate?
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® ❑ Were the septic tank manholes uncovered, opened, and the in erior of the tank
inspected for the condition of the baffles or tees, material of co istruction,
dimensions, depth of liquid, depth of sludge and depth of scu ;?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage; isposal 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.
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® ❑ 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(, )]
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D. System Information
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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 plus
GPD
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t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage isposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is required for every Cotuit Ma. 02635 12/21/2017 page. Cityrrown State Zip Code Date of Inspect on
D. System Information
Description:
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Number of current residents: 0
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? I
❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): i
Detail:
In 2017 8,000 gallons were used and in 2016 32,000 gallons were used
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Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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
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Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
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Water meter readings, if available:
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t5ins.doc•rev.6/16 Title 6 Official Inspection Form:Subsurface Sewage Di sal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 12/21/2017 i
page. Cityrrown State Zip Code Date of Inspect on
D. System Information (cont.)
Last date of occupancy/use: Date
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Other(describe below):
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General Information
Pumping Records:
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Source of information:
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Was system pumped as part of the inspection? ❑ ' es ® No
If yes, volume pumped:
gallons {
How was quantity pumped determined?
Reason for um in
P p 9:
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Type of System:
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® Septic tank, distribution box, soil absorption system
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❑ Single cesspool !
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection recor;s, if any)
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❑ Innovative/Alternative technology.Attach a copy of the current ope ation 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.
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❑ Other(describe):
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t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Di'josal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava I
Owner Owner's Name !
information is required for every Cotuit Ma. 02635 12/21/2017 f
page. Cityrrown State Zip Code Date of Inspect'on
D. System Information (cont.)
t
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ es ® No
Building Sewer(locate on site plan): '
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Depth below grade: 36" I
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
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Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
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Septic Tank(locate on site plan): 1
3 �
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene other(explain)
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If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ! Yes ❑ No
Dimensions: Standard H-10 1,6 00 gallon septic
tank
Sludge depth:
t5ins.doc-rev.6116
Title 5 Official Inspection Form:Subsurface Sewage Di.{posal System-Page 9 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is required for every Cotuit Ma. 02635 12/21/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
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Distance from top of sludge to bottom of outlet tee or baffle
36"
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Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to'bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, s,ructural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I would recommend the new owner put the tank on a maint. plan with a local septic' umping co.The
Barnstable Health Dept. has a list of local septic pumping co. !
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Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
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❑ concrete ❑ metal i
❑fiberglass ❑ polyethylene other(explain):
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Dimensions:
Scum thickness
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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
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losal t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Dis System-Page 10 of 17
Commonwealth of Massachusetts
ugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is required for every Cotuit Ma. 02635 12/21/2017
page. City/Town State Zip Code Date of Inspect.on
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, sl ructural 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, Ian):
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.):
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*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Dis' sal System•Page 11 of 17
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 12/21/2017
page. Cityrrown State Zip Code Date of Inspe d ion
D. System Information (cont.)
f
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
I ran my camera down the outflow pipe and I did not see a D-box.
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Pump Chamber(locate on site plan):
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Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ' ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
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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:
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t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Dis' sal System•Page 12 of 17
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Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°tee 10 Cotuit Bay Drive i
Property Address
Andrea LaCava
Owner Owner's Name 1
information is required for every Cotuit Ma. 02635 12/21/2017
page. Cityfrown State Zip Code Date of Inspe ion
D. System Information (cont.)
Type:
® leaching pits number: One
❑ 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, dam; soil, condition of
vegetation, etc.):
At the time of the inspection the leaching was dry and there were no visible_signs f past hydraulic
failure. i
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Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):'.
Number and configuration
Depth—top of liquid to inlet invert
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Depth of solids layer
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Depth of scum layer
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Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes i ❑ No
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage El isposal System•Page 13 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•' 10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is
required for every Cotuit Ma. 02635
12/21/2
page. Cityrrown 017.
State Zip Code Date of Inspe' ion
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Privy(locate on site plan):
Materials of construction:
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Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condit on of vegetation,
etc.):
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t5ins.doc•rev.6116 Title 5 Official Ins pection Form:Subsurface Sewage Disp sal System•Page 14 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 12/21/2017!
page. Cityrrown State Zip Code Date of Inspe; ion
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal syste c , 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
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t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Di s osal System•Page 15 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,•• 10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 12/21/2017i'
page. Cltyfrown State Zip Code Date of Inspe ion
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar j
® Shallow wells
Estimated depth to high ground water: 14 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
® Observed site(abutti
ng g property/observation hole within 150 feet of S )
❑ Checked with local Board of Health -explain:
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❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
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You must describe how you established the high ground water elevation:
I au ered a hole at a lower elevation and shot it with a transit.
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Before filing this Inspection Report, please see Report Completeness Checklil t on next page.
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disp sat System•Page 16 of 17
w
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 Cotuit Bay Drive
Property Address
Andrea LaCava
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 12/21/2017
page. Cityrrown State Zip Code Date of Inspe f ion
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems) corr pleted
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached,in se,arate file
A-A C.
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t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Dist sal System-Page 17 of 17
ell TOWN OF BARNSTABLE
LOCATION C L ��f/1EWAGE # I. (5 10
VILLAGE C tV ASSESSOR'S MAP Cr LOTOu5�-6VI
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY ►,®�C�Q C�C�i L t ►�
LEACHING FACILITYA ype) (size) w M''T A 9
NO. OF BEDROOMS- PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER l,GcLouG�
DATE PERMIT ISSUED: � 1 S
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No y
(lp
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No.. 2�_.��r _ F�$. ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Nppliratinn for Di-nipw3al Workii Towitrnr#inn Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair (%/an Individual Sewage Disposal
System at �+
sl
Location•Adds or Lot No. __..._ ^-••-
1 CA_C-•E�_C 4........................ w.....__._................_..
` Owner {r �ndd ss ^�
� Installer Address
UType of Building /1 .�-'�` Size Lot............................Sq. feet
a Dwelling—No. of Bedrooms._--•- ---------- ---_-.___Expansion Attic (��') Garbage Grinder
04 Other Type of Building -----------------------_--_ No. of persons5....._..�_Z2..T__._. Showers ( ) — Cafeteria ( )
04
C11Other fixtures . .�`..... r-•------------..........-•----••---•------....-•------•-----•-••------------
W Design Flow....................................... gallons per person per day. Total,daily flow--------------_-----_--..._---._-----_--_--_gallons.
WSeptic Tank—Liquid capacity_/6.....�allons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1-_-----_---__-minutes per inch Depth of Test Pit.................... Depth to ground water........................
�X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 9 •--•----------•--•----------------••--•-------•-•-•---•----•------•--------......---........._.--•--.........................................................
Description of Soil........'----•----•--.....---••-••---------------•-•----•----...•-•-•-------•---••-----------•-•---------...........•----••••------------•--...-•-•-----.............._..
- -----------------------------------------------•-------•--------------------------------_.........W ...............••-••--•-----•••--•-•-•----..._•-------•--------...--•-•------W j�
.4 U Nature of Repairs or Alteration —Answer when applicable.... ------------------- 9. _. .1:_.... _SC. ?...__.
.--....�.._--�---�k..... �- -----------------•---•------•-----------------•-----•---------•-------•---•-----•--•-----•-•---•---------......---•----•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions-of TITLE 5 of the State Environmental Code—T e unde s greed further agrees not to place the
system in operation until a Certificate of Compliance has bee��n^^iss ed by e board of health.
Signed .... .. .. - /. .y..fS..S
Dace G
Application.Approved BY J' y.. .,e .. . ........
Date
Application.Disapproved for the following reasons: ..........
. ....................... ................. ................................ ....... ........ ................... ........................ . ..... ........................................
Dace -
Permit No. ..:...... ................ Issued ''1 C''
.......... ... ............../��J..- e!.- ...-...
0 Dace lr. i.. ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
t ' Ter#tf rate of Tomplianre
THIS S TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �)
by..........................d. ....r ......(--..c-"!/" /. ................................
..............................................................................................
InsnJler
at . 1. ......CU......�J.A........�'.5.y.--- -.(l,).r. -----------� -
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ....... �°'.-. .. . � dated ._L ..^'.� ..' _?'SN—.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... ....' . .. ` `�. ------------------------ Inspector -----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J TOWN OF BARNSTABLE
No...91.' a�/0 FEE._.� ? .'...
�i��rnnttl nrkn �nn,�tr�rtinn �rrntit
Permission is hereby granted---------•--------------•--------•---------------------------------------------------------------------•-•----------------•-----••-----------
to Construct ( ) or Repai r ) an Indivi al Sewage Disposal System
atNo...............\-6......COA-J.Z 3155; ..............cc-A'.......... -----••-•---------------------•--•••-•-•..... ....................................
Street
as shown on the application for Disposal Works Construction Permit No..�.:_ l�_ Dated.....
.- .............
........................... ...............................................................
Board of'Health
DATE .......... •. = ........
FORM 36506 HOBBS&WARREN.INC..PUBLISHERS
r77
op /20.00
v . o CO
40
i
s
QH
ZOTUTT BA"i- _-Aq
I 40 ' wr •�
Seale 1"'40'
IQEaTIFIED PLOT*% ?LAN
Being lot as• shown on a
1 subdivision ,,pplazl. .entitled
certi'f . that I,Cotuit Bay Shores" located in
I, hereby Y. , Cotuit Mass'.-, Dated Jm.-.3,1
975
the existing ound tion ; and recorddcr-in Barnstable
locati,oq..is correct as ? Registry of -deeds, in book
shown and .-does conform i 292 page 26.•
wi � ,tie ,building setback i
.0 0z re Virements of the. Town July 6th, 1976
of Barnstable.
1"a"a:I. Builder:,
8 -IA sW i Charles F.' Stanley
4h�'��sTCP�y�QN Centerville, Mass. I
1
SUM sigfled
, .-• /fl ca�-c..3���y�'P%vim
- 4 8
�" - OhcJ�✓E1�:i�ieEGo� �A vy
2
TOWN OF BARNSTABLE r
�9n 30o UNDERG,.ZOUND FUEL AND CHEMICAL STORAGE SYSTEMS ow� �
a-7 ASSESSORS MAP PARCEL NO. �
arm '/317 yyaa
ADDRESS: /8.S-ca VILLAGECo7-u,i
CONTACT PERSON pE�,p„ Gv a ��' �_ PHONE NUMBER_ 4 8 - 4478
.LOCATION OF TANKS: CAPACITY: -..TYPE OF FUEL. GE: TYPE: LEAK
�O OR CHEMICAL: DETECTION
SYSTEM!
�� 2M GALS FNEG O/G -77 9 aSTEEc
(a,000)
DATE OF PURCHASE OF. EACH: 1. 2. 3. 4. 5.
DATE'. UF° FIRE DEPARTMENT PERMIT: Au4 zz_ i979
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THiE LOCATION OF TANKS ON THE BACK OF THIS CARD.
A�'A6�lfl
jam. �L v
I _
p
p"9'4NDC
CaTul'-
r"f1r111 A.r'�r..:r r':e_ fl�rr Trl.4 QQQn4?nnnn A4 14n InA4n 4n.Gn.4? 11�)nG n nA9 /AAA
sS u
GOTV��. COTUIT FIRE, RESCUE & EMERGENCY SERVICES
64 HIGH STREET • P.O. Box 1632 • COTUIT,.MA 02635 u
jOFFICE (50a) 428-2210 + FAX (508)428-0202 • WWW.COTU'I7FIRE.ORG , !*
G
c y]
:�
�„D
Date: January 10, 2019
#of pages: 4(including this cover sheet)
Please Deliver to: Bob Churchill
From: Chris bauley @ Cotuit Fire & Rescue
Message:
Good News! A little more digging in our older files and I found the appropriate
paperwork/certificate to show the proof the oil tank has been removed.
Hope this helps!
Chris
I
Confidentiality Notice: This fax transmission may contain confidential information belonging to the sender which is legally privileged and which is
intended only for the use of the individual or entity named above. Any copying,disclosure,distribution or dissemination'of this information or the
taking.of any action based on the content of this communication is strictly prohibited. If you have received this transmission in error,please notify
us immediately by telephone and return the original transmission to us by mail or delivery at our address above;the cost of which shall be paid by
us.
FROM:Cotuit Fire Dept TO:18883169093 01/10/201912:50:51 #335 P.002/004
Cotuit Fire Department. pT It
Fire, Rescue & Emergency Services G ?�
• 64 High St. - P.O. Box 1632
nu Cotuit, MA 07-645
W
Paul A: Frazier Phone (508) 428-2210
Chief of Department FAX (508) 428-0202
TO: Tom McKean, Director.of Public Health
Town of.Barnstable, Board of Health
P.O. Box 534
Hyannis, MA. 02601 Q
FROM: Chief Frazier, Cotuit Fire Department
SUBJECT: Tank Removals, et al
DATE: May 29, 1996
The following.tanks have been removed/abandoned since my letter dated October 27,
1995.. If you need further information,please feel free to call me. Thank'yoia:
777--7
tw Ave. 1/19/96 500 gal .tank removed,
5 no contamination or
odor preent.
w rAve. 1/19/96 1,000 gal. tank
removed;no
Contamination or odor
Present
ew Ave. 1/19/96 30(Y 'tank removed,
635 r16, tamination or
�r preserlt
ee Dr. 2/21/96 750 gal. tank removed,
'635 no ContaMindbn or
odor:present
Lacava, Gregory 10 Cotuit Bay Dr. 4/24/96 2,000 gal.tank
Cotuit, MA 02635 removed;no.
contamination or odor
present. .
FROM:Cotuit Fire Dept TO:18883169093 01/10/2019 12:51:21 #335 P.003/004
(rev. 9I80j
y
c�tjl' C�niitntnttwpttlth of �(tt��ttr�ti�r�t�
Department of Public Safety
Division of Fire. Prevention and Regulation
APPLICATION FOR PERMIT, AND PERMIT, FOR REMOVAL AND TRANSPORTATION TO APPROVED TANK YARD
FDIDI 01921 Permit i�._—_, Dat®
c tuit
City,Town of Wsidat C .8 2 1 .40 N.0 . 4
DIG :SAFE NUMBER
Fee PaidtS _ cl qt
start date.'A N=S
In accordance with the provisions of Chapter 148, sec. 36A, M.G.L. ,
c
527 CMR 9,00 application is hereby made bys
Street Address & City or Town? (s ,10 A_:� S 1 O's\'�z
Signature.. o.f. applicants
Applicants name printed: :l�clur-
For permission to remove and transport one underground storage tank from.
Owner n ^. . ,
u Street Address: �a. � � j �
Firm transporting waste: EY\�, S � State Lia.
Hazardous waste manifest E.P.A. .
Approved tank yard t-T��r.c�S+����o�. pQa
Tank yard Addressi. ` \Me/`p� ��-�_ �4,
Type of inert gaaI1' rt, UL tank ft
Tank capacity t Substance last stared: CR �./.
Date .of issuer Date of expirati ti
19
Signature/Title of Officer granting permitt
KEEP ORIGINAL AS APPLICATION AND ISSUE DUPLICATE AS PERMIT
FROM:Cotuit Fire Dept TOA 8883169093 01/10/201912:51:59#335 P.004/004
V
Tank
a
Tank Removed From:
Galion s � 011-'11
Previous Conten ( o. and Street )
Diameter___- �I,ea tb;z- 1 f Clt, '
s Date Receive ?
Serial # Fire Dept. Per #
(if available)_____`_
Tank I.D. # (Form FP.290)____
Owner/Operator to
290R) .toi UST mail revised co
py Compliance of Of Notification Form(FR290
Commonwealth Uffice of the State Fire or Fp.
Avenue, Boston, Ma.. 02215. Marshal; 1010
RECEIPT.D O
NAME ANF DISPOSAL OF UNDERGROUND:STEEL STORAGE
ADDRESS TANK
OF
APPROVED'TANK YARD
APPROVED TANK YARD N0. A, 01 -
Tank Yard Ledges 502 CMR 3.03(4) Number:
I certifyunder
penalty-of law I have personally exanused the unde=Auwd steel storage
delivered:"to this"""approved tank yard" by fim, corporation or partnership
and acre
prep same g iderginanoe.with Massachusetta:Frre Prevention
va atiois.502 CNflt.3:00 Provisions for Approving tJridt,egroiy " Steel S A valid.permit was:issued by LOCAL Head of Fire Deparbrent FD wlantlirg yards.
this tank.to this yard. to transport
official title of approved Yard owner exs authorized-representative:
SIQ r
GATE S
FD� local
s ai4ned receipt of disposal snsst be returned to the head of the fire departssmt
————,.pursuant to 0 CMt s 00. WRA H 194bHt MAR'HAVE A AFJC�'P CF DISpOML►
FORM. F.P. 291 (rev. 11/95)
MSSAQKA M SW= FIRE WSPAL`S OFFICE
16
bA-u _ S S- D a 3
i
I
i
S M E A
KEEPING YOU ORGANIZED
No. 10534
2453L
WME IN USA
GET ORGANIZED AT SMEAD.COM