HomeMy WebLinkAbout0023 COTUIT BAY DRIVE - Health 23 COTUIT BAY DRIVE, COTUIT
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TOWN OF BARNSTABLE toT S I
LOCATION �3 COTU T (�LAy 7r, SEWAGE #
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VILLAGE CO Tv 1 ASSESSOR'S MAP & LOT P — O a 1
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /SOO GAL
LEACHING FACILITY: (type) P%\5 (size) (OX(0
NO.OF BEDROOMS y
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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COMMONWEALTH OF MASSACHUSETTS
ExECUTrvE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENviRoNMENTAL PROTECi'ION r°,+
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 „>
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WILLIAM F. WELD _
Governor — TRUDY COXE
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ARGEO PAUL CE
4 Secretary
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Lt. Governor �" a yNo DAyVID �STRUFIS'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM yoFPrgCgtsuniaa
PART A
CERTIFICATION
Property Address: 23 Cotuit Bay Drive, Cotuit, MA Address of Owner:
Date of Inspection:. September 1, 1998 (If different)
Name of Inspector: James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 0265S-0049 Map: 055
Telephone Number: (508)862-9400 Parcel: 021
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:
✓ Passes
Conditionally Passes
Needs Further Evaluation By.the Local Approving Authority
Fails
Inspector's Signature: Date: September 3, 1998
The System 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:
A] SYSTEM PASSES:
✓ 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:
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.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why.
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.
(revised 04/25/97) Page 1 of 10
DEP on the world Wide web http./Mrww mapnet.state ma.us/dep
.Printed on Recy0ed Paper,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 23,Cotuit Buy Drive, Cotuit, AM
Owner: f`Ed Meiners
Date of Inspection: September 1, 1998
B] SYSTEM CONDITIONALLY PASSES (continued)
_ '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:
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(SAS)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 1 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
(revised 04/25/97) Page 2 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 23 Cotuit Bay Drive, Cotuit, AM
Owner: Ed Meiners
Date of Inspection: September 1, 1998
D] SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I ha
ve a determine
d 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 1/2 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 portion 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 1 of a public well.
An y 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. 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:
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 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)
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.
(revised 04/25/97) Page 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 23 Cotuit Bay Drive, Cotuit, MA
Owner: Ed Meiners
Date of Inspection: September 1, 1998
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, and Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
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 iystem components,excluding the Soil Absorption System, have been located on the site.
✓ _ 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.
✓ _ 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 is
unacceptable) [15.302(3)(b)].
r
(revised 04/25/97) Page 4 of 10
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
-SYSTEM INFORMATION
Property Address: 23 Cotuit Bay Drive, Cotuit, MA
Owner: Ed Meiners
Date of Inspection: September 1, 1998
FLOW CONDITIONS
RESIDENTIAL: µ
Design flow: 440 g.p.d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: 2
Garbage grinder(yes or no): Yes
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last two (2) year usage (gpd): 1997-50.000 gals.: 1996- 68,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gallons/day
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:
OTHER: (Describe)
Last date of occupancy:
M GENERAL INFORMATION
PUMPING RECORDS and source of information:
PumrJed in 1997- per owner.
System pumped as part of inspection(yes or no): No
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank/distribution box/soil absorption system
Single cesspool y
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: Unknown.
Sewage odors detected when arriving at the site(yes or no): No
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 23 Cotuit Bay Drive, Cotuit, MA
Owner: Ed Meiners
Date of Inspection: September 1, 1998
BUILDING SEWER: _
(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: Yes
(locate on site plan)
Depth below grade: 24"
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: 10'6"Lk 5'8" X 5'8" (1500 gal.)
Sludge depth: 21,
Distance from top of sludge to bottom of outlet tee or*baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: 11"
How dimensions were determined: Measuring stick
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.) The bales were present. There were no signs of leakage. The liquid level was even with the outlet
invert. Recommend riser be installed on inlet side of tank.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet 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.)
(revised 04/25/97) Page 6 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 23 Cotuit Bay Drive, Cotuit, MA
Owner: Ed Meiners
Date of Inspection: September 1, 1998
TIGHT OR HOLDING TANK: None (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: Yes ~
(locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
The D-box was level and there were no sixns of solids.
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order(Yes or No):
Alarms in working order(Yes or No):
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.) "
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 23 Cotuit Bay Drive, Cotuit, AM
Owner: Ed Meiners
Date of Inspection: September 1, 1998
SOIL ABSORPTION SYSTEM(SAS): Yes
(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: 2-6'X 6'
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.)
The soil was a sandy loam. There were no signs of failure or ponding. The bottom to grade was 8'6"
CESSPOOLS: None
(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: None
(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.)
(revised 04/25/97) . Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 23 Cotuit Bay Drive, Cotuit, MA
Owner: Ed Meiners
Date of Inspection: September 1, 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).
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(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 23 Cotuit Bay Drive, Cotuit, MA
Owner: Ed Meiners
Date of Inspection: September 1, 1998
Depth to Groundwater: feet (from top of leaching mound)
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V' 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)
Hand augered down to 13'on the lowest point on the lot, which was considerably lower than
the pit site. No water was observed.
This report has been prepared and the system inspected and passed as of September 1, 1998. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either
expressed, written or implied, relating to the system, the inspection and/or this report.
(revised 04125/97) Page 10 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
Address of property Cp�'�/�'f Re-t- �
Owner's name
�p'Clid f
Date of Inspection
PART A AUG 2 9 1995
CHECKLIST
Check if the following have been done: TM OFBAF{NUABLE
Pumping information was requested of the owner, occupant, and Board of
Health. -
None of the system components have been pumped for at least two veeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
Abuilt 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.
C�
The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
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 SAS on the site has been determined bad
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance -of SSDS.'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
number of current residents
_ garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
j
3
System pumped as part of inspection, yes or no "
if yes, volume pumped _
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)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:. l
Sewage odors detected when arriving at the site, yes or no
i
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:__/,700
(locate on site plan)
depth below grade:1
material of construction: concrete metal FRP other(explain)
dimensions:_ <'7� L X
sludge depth
-.�`cdistance from top of sludge to bottom of outlet tee or baffle
—� scum thickness
NA distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outle� tee or baffle
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, recomm d ions epairs, etc. )
DISTRIBUTION BOX:���
(locate on site plan)
t� depth of liquid . level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evide a of leakage i t r out of box, re omme da epairs, etc.)
PUMP CHAMBER:
(locate on site plan)
pumps in working o r, yes or no
Comments:
(note condition of pump cha condi n of pumps and appurtenances,
-- recommendations for m enance or repairs, tc, )
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM ' INSPECTION FORDS )
PART B
SYSTEM INFORMATION continued
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. C .
leaching pits and number 2 o a
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
conditio of vgetati n, recommendations for maintenan or repair$,etc. )
op �vv
CESSPOOLS (locate on site. P lan) :
number and co figuration
depth-top of liquid to inlet invert
depth of solid layer
depth of scum la er
dimensions of cess of
materials of constru 'on
indication of groundwat
inflow (cesspool mus p ed as
part of inspecti
Commen s:
(note condition of soil, signs of hydraulic fai e, level of ponding,
condition of vegetation, recommendations for mainte nce or repairs,etc. )
PRIVY:
(locate on site pl
materials of construction
dimensions
" depth of solids
Comments: f '
(note co i of soil, signs of hydrau 'c failure, level of ponding,
conditi of vegetation, recommendations fo aintenance or repairs,etc. ) .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE ii=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
f,
DEPTH TO GROUNDWATER
5 or
depth Ito* groundwater
met hoc of determination or appk3 'mation:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup of sewage into facility?
Discharge or pondinqE of efflilent to the surface of the ground or
surface waters? `
Static liquid level in th ribution box above outlet invert?
/V_,414- Liquid depth in cesspool <6" below invert or available volume< 1/2 de
flow?
_Required pumping 4 times or more in t e last year?
number of times pumped 7 ,¢ 1,9 F y
' V Septic tank is metal? cracked? structural) unsound? substant'
Y ial
infiltration? substantial exfiltration? tank failure imminent?
/Jr Is any portion of the SAS, cesspool or privy:
below the' high groundwater elevation? �,�
within 50 feet of a surface water? '
./Z-/within .100 feet of a surface water supply or tributary to a surface
PP Y Y rf e
water supply? �-c,,.r.-,.,_
J_Vwithin a Zone I of a public well? %,�
- j�G�
f within 50 feet of a bordering vegetated wetland or .salt marsh ,
(cesspools and privies only, not the SAS) ? _
L a
A2within ,,50 feet of a_ private water supply well?
less than 100 feet but greater than 50 feet from _.a_. .r_iv- .. ._"..
g r t p ate water
supply well with no acceptable water quality analysis? "" If the" well
has been analyzed to be ' acceptable, attach copy of well water Ana -
for coliform bacteria, volatile organic compounds, ammonia nitrog
and nitrate nitrogen.
TOWN OF BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADD
RESs a Co v i 13.E p`7.
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME o sAe&
PART D - CERTIFICATION
NAME OF INSPECTOR
COMPANY NAME L/ /0 �� G �
-
COMPANY ADDRESS
Street Town or City State ZIP
COMPANY TELEPHONE (_j_6� 3 (62- - 30 FAX
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposil system at
this address and that the information reported is true, accuratef . and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance., and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems.
Check .one:
Sys
tem PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED
The inspection which I have conducted has found that the system fails tc
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 .303 , and as specifically noted on PART C FAILURE
CRITERIA of this i sP tion form.
Inspector Signature
Date
-
One copy of this certification must be provided to—the OWNER, the BUYER
(where applicable ) and the BOARD OF HEALTH.
If the inspection FAILED, the owner oroperator shall upgrade ' the system
within one year of the date of the inspection, unless allowed or required
. otherwise as provided - in 310 CMR 15 . 305 .,
partd.doc
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TOWN OT" NSTABLE
iLOCATION3 04U t U A G SEWAGE # L ell gC
VILLAGE ASSESSOR'S MAP & LOT
.INSTALLER'S NAME & PHONE NO. 4 � jZ
SEPTIC TANK CAPACITY A)
LEACHING FACILITY:(type) / (size) -0O
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
By�t R OWNER
,:DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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gie,d -" `�'N OF BARNSTABLE b s •$ O at Tc
Appliratiott for Bi-aipm3al Works Tomitrnr#ion Vantif
Application is hereby made for a Permit to Construct ( ) or Repair (X� an Individual Sewage Disposal
System at:
23 Cotuit Bay Drive Cotuit
..........- •---• ............................................................. ......•----------••-------••••------•---------•...--••------••---•••......-••----•---•............
Location-Address or Lot No.
Mr . John Costello -•--------------------------•-•--••---......--•-••••-•-.......••---...............................
Owner Address
W J .P.Macomber Jr.
Installer Address
UType of Building Size Lot............................Sq. feet
DwellingX No. of Bedrooms_______________3------------------.--------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures .....................
W Design Flow............................................gallons per person per day. Total daily flow......................................._....gallons.
WSeptic Tank—Liquid capacity------------gallons 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ •---•---•------•-----------------------•------------------...--•---------------.....-•----•-•-••----.........................................................
0 Description of Soil--------------------------------------------Sand-----------------------------
x
U -------------------------•-------------••-•------------------•---•-------•---------------•-••-•-----------•-----------------------•-----•--•-...----...--------------•----•-----------------••••---•---•
W
x --- ------------------------------------------------------------------------------------•------•-------------------------------------•......----------------•••-----••--------•---------.....--•-•-•----
U Nature of Repairs or Alterations—Answer when applicable-------------1--6-'-x7 '_--leach--pit-_-packed in stone.
.Add-in .._to_• xistinnitwith a d-box.
- g....................... - .-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not-to place the
system in operation until a Certificate of Compli nce hasletssued by th boa of health.
Signed 3/29/94
... ... -- .. .... ................. .. .. .............. .................15;...... . .........
�! Dace
Application Approved By ............ �.. � ... -.. �. .v.....' �7
Dare
Application Disapproved for the following reatonr: ......... ......... .. ....................................................................................
-------------------------------------------------------------------- ......................................................... ........................................
Date
PermitNo- ------------------------------------------------------------------ Issued .............. .......... ......................
Dare
r, �,
Q 1f f, .p
THE COMMONWEALTH OF MASSACHUSETTS
�',,,,�BOARD OF HEALTH v
T�b�N OF BARNSTABLE 0 s S O a ( �c.
= _ Applirtt#iun for Diu uuttl Wurk,i Cnunu#rur#'inn -prruti#
Application is hereby made for a Permit to Construct ( ) or Repair ()C.j�`an Individual Sewage Disposal
System at:
,1
23 CotuRt Bayt Drive 'Cotuat
---------------------•-•-•----..........------.........--•-------....................--„-... -•---•--------------------••--•--------...-•-••--•----•----•---
Location-Address or Lot No.
Mr. John, Costello
......................-.......................................................................... ................................................
Owner Address
a J.P,,Ma.comber Jr. ` `' .. `°.....:...:...'_ �4_......_.._..__......__._.._..............._.
--------------
Installer Address
UType of Building Size Lot............................Sq. feet
DwellingX No, of Bedrooms_______________3
---------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons-__-______-_-______---..---- Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------- ---------••-----------••-•-•-......------ --..._...-••-•------••-----••-•-•-•••-•-•--------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.............gallons 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 ( )
aPercolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water......................
Lit Test Pit No. 2................minutes per inch Depth of Test Pit------.---______-- Depth to ground water........................
94 ....--•--•••----------------••••--•-••..._............•-••••......-------••-•---•--..........------.........................................................
0 Description of Soil.............................................Sand
x
w
-------------------------------------------------------------------------------------------------•--------------------.....-----....------------------------------------------------------....-•-.......
U Nature of Repairs or Alterations—Answer when applicable.............1.-6_'-x7' 1each.__pit,r_r)acked. i.n stbne .
_Add.inq...to..._existinc_.tank__ & pit with a.cd-box. '
• --------- -- --------- - - -----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has, ee issued by the boar:,d of health.
3/29/94
/
Slgned .... ...... ..........f,...'i l Iids?ice- ................................... .
......_.-.....Date................
ApplicationApproved By .............. ..y:<w� ......... ......... -----...------------------------- ---------------------_------------may^. ..., .. /�-u---�-•�\ Dare
Application Disapproved for the following reasons- ----------------------------- ------------------------------------------------------------------------------------------------------
----------------------------------------------- ---------------------------------------------------------------------------------------------------------------- .....................- -----------------1..te.............
Dat
PermitNo. .................................................................... Issued ................-- .-- .......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
EICtifirate of Tampliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XX )
byJ.P.Macomber, Jr- - ------------------------------------ -f-----i..f... -' ......... ........... .!-------------x.....1..: ....... ............--------------------------------------
1.
at ...2.3.....C.otui;t Bay, priv6 Cotui,t
.. .. .. . ...........::.................... .. ........................................................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described inq
the application for Disposal Works Construction Permit No. -.-! �/-...11.6..._..---------- dated ---------------------------------------------
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
TOWN OF BARNSTABLE 30 00
No.... FEE................. .:1
�tu�nuttl Turku �unu#r�r#inn �rrnti# _--
J P.Macomber Jr.
Permission is hereby granted------___'.
_ i ---•------------------------
to Cons uct ) o Fgair X-5' �. an le.
dividual Sewage Disposal System
�rI rr •• !S ... 1t
at No...l Cb....... 1-•,•aY , r v •---ofu--•---•-•---------•-----...•-----
Street
as shown on the application for Disposal Works Construction Permit No ._ _:_ ._ Dated__-_--._, ._:� ..:i
DATE_ y y-----••......----- v Board of Health
c
rFORM 36508 HOBBS&WARREN.INC..PUBLISHERS
No...... .
---•---------- ------ .1 Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Oza3. .._...........OF.......J �a� �...........................................
ApplirFation -for M,q uoal Works Tonfitrurtion Vrrnift
Application is hereby made for a Permit to Construct 06 or Repair ( ) an Individual Sewage Disposal
System at:
._.._.._..�_�_v..... ._b .............................................. •-• .. -
Location-Address or Lot "o.
Owner / Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder (�
Other—Type of Building No. of persons............................ Showers ('2--) — Cafeteria ( )
Q' Other fixtures ------------------------------------------------------
W Design Flow.........110...........................gallons per person per day. Total daily flow------q`z_!5�........................gallons.
Septic Tank—,Liquid capacity/S 'gallons Length................ Width----------- .... Diameter------.--------- Depth---------.-----.
xDisposal Trench—No._.__.•`_.____._.___ Width.................... Total Length.................... Total leaching area--------------.-----sq. ft.
Seepage Pit No.__J ...... Diameter...6?�------ Depth below inlet____________________ Total leaching area----'2,7-�—.sq. ft.
z Other Distribution box (1) Dosing tank ( ) 4 A9CIA, /;t'If-7 7
aPercolation Test Results Performed _______________________ Date._ -.1 ,._7-7-_-__--..---.
Test Pit No. I___,4:�:----minutes per inch DeptK of Test it____________________ Depth to ground water---------..-.-_:--.--.--
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--._..---__---_---__.-:.
f
0 P 1 --
- --------•-- --
------------
Description of Soil- 0".2 a- - '''r�` _ ._/ ....-- r�__(_. V
x
VW •--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------..........
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 XI of the State Sanitary Code—The undersigned furth agrees not to place the system in
operation until a Certificate of Compliance has been issued b the b rjd f eal
_L _Si ed --•--4�'---•--•--•-----------------• .
Date
Application Approved By------ � � ____
Date
Application Disapproved for the following reasons:...............................................................................................................
---------•--------------------------•-----`-----•••-------------•------- _---- - ------------ - - --
4 Date
Permit No........s--,:&-1'2 --- �f� ' �� Issued..... /--
Date
v Y L.
6_0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
u,. AttrAST►4 (e
_..... . . ---------OF......'t✓..................................................................
Applirtttion -fur Di-qVuiittl Works C omitriartion Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: *
co-ro tT t o tJ�l L)
............................... --------------------------•••-••••--••----•-••-------•-- --•-••••-•----------•••---•-••----•--•-•-••-•••-...••••---•••--•----••-••-••-•-•••---•--.........
-A .
04b
Loca' ddress
,1 / 77
or Lo o.
Al
A :�� f-v t-d.n,�+ _..._... f� T 1 Cadr M/tCc
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms. .........�............................Expansion Attic ( ) Garbage Grinder
Other—Type of Buildint 1 tskht
aYP g -- ------- No. of persons............................ Showers ('2—) — Cafeteria ( )
Other fixtures ------------------------------------------------------
Design Flow......___..................................gallons per person per day. Total daily flow...........9----------:---------------....gallons.
WSeptic Tank—Liquid capacity/5pOgallons 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 ( ) d6• ekl)4, /2 /f- 7 1
aPercolation Test Results Performed by.04,,.---li . -- _.._�ti[� . ........................ Date,/ .-..1 _a_ 7.-.__-----.--.
4 Test Pit No. 1---/-?r.-----minutes per inch Deptfof 'Pest it.,.................. Depth to ground water------------------------
4, Test Pit No. 2................minutes per inch Depth of :Pest Pit.............._----- Depth to ground water...-.-------------------
�I f P------ --------•--- -- . I ------.... - - --- - -------
O Description of Soil - �r v'!-r�..�]f._�5-sr� _.. :2 id /2u i. /f._. ,rt1
V ...............................--........................................................................................................ '
----•------------------•-•---- --------------•---------•---------------------------
V 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 XI'of the State Sanitary Code— The undersigned furth agrees not to place the.system in
operation until a Certificate of Compliance has been issued b the b rd f eal.Q
Date
Application Approved B :... ,F�d�f i.��tij__
Date
Application Disapproved for.Vie following reasons:...........................:____.__...._..................................................... .......... ......... --- I......•. ---•--
............... •.- ............. ...........................
7 Date
Permit No. •--------------------------- st Issued F --------- =° --------•--•----•••--•-= ......... "
Date
- - �i..: ...'J. .,..�.>• -, w.s,..�.. ..x.. �.'. . ..-�,.A w..,4.^¢"�� 'w"C.."'.`ai`k' +1..r<.w+n .-. �- •F.:. � y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
011rrtifirttte of Tom, rlittnrr
' THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
bY-......--•-•JA D i`!�.k..-- d,-' ...................................-.......................................................
-----------------------------------=
I 2er
.r- -- --�
has been installed in accordance with the provisions of XI
f The State Sanitary Cody described in the
application for Disposal Works Construction Permit N ......................................... dated..-...y ..:_.__4 7d ..:___......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCT ON SATISFACTORY.
DATE-------e-- Inspector--
•-------•-------- -•-_----- ---•--•------•-•----•--•-----•--•-•---......-••----•--•-----••••---•---_-_....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............t.f�. N�............OF....... ./�.h.ti.l..�r tA,b !�./� . _. 2.7
No......................... ............. FEE........................
• ��i����t�tt���--;;�l��xi 1�1Y�,�,� ��yYrttl�Bt �Prlltt�
Permission is hereby' ranted---------C.ve,�lL ------1 � "—
Y g ---------------------------------------------------------•...•----•------------••••...........
to Construct (fi r .Repair an Individual Sewage Di oral System
/at No. ? f =a U( A l!1-��..... _�14�u w. �v..� � ---------------•
Street
as shown on the application fo Disposal Works Construction Piit ... Dated----
. .-------------
Board of He th
DATE. --------------6 -----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
3 SS +50
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L O CATION j,� . EW* A.GE PERMIT N0.
T r
VILLAGE
IMSTA LLER'S NAME & ADDRESS
B U I L D E R OR
DATE PERMIT - ISSUED ` � �� �
DA.T E COMPLIANCE. . ISSUED
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