HomeMy WebLinkAbout0525 COTUIT BAY DRIVE - Health 525 Cotuit-Biy--'rive
Cotuit P
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TOWN Or BAF.NSTABLE
LOCATION coruil qv Dr, SEWAGE#
IN-LAGE C�V11 ASSESSOR'S MAP & LOT®�5��3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY l J /�-�-•
LEACHING FACILITY: (type) (oX 6' !'�/ (size)
NO. OF BEDROOMS 3
I' BUILDER OR OWNER MArG��q l-�AL
PERMITDATE: COMPLIANCE DATE:
Separation Distance"Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching fjcility) Feet
Furnished by _Srl.t1JlGc.'7'llx� ' �- FD�l
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Town of Barnstable
OF'[HE r Regulatory Services
Thomas F. Geiler,Director
Public Health Division
BARNSTABLE, Thomas McKean,Director
9 MASS.
�j 1639. 200 Main Street, Hyannis,MA 02601
prFD MA'l A
Phone: 508-862-4644 -
Email: health@town.barnstable.ma.us
Fax: 508-790-6304 D
Office Hours: M-F 8:00 4:30 O ��
July 21 2009
Harold and Ann Quinlin RE: Underground Storage Tank Removal
525 Cotuit Bay Drive Order,525 Cotuit Bay Drive,Cotuit,MA
Cotuit,MA 62635 Map Parcel 055053
Tank#1 Tag#00560
Dear Sir/Madame:
The Barnstable Public Health Division(BPHD)is in receipt of a copy of the"Application and Permit"
for storage tank removal and transportation issued by the Cotuit Fire District,and the"tank yard"receipt
demonstrating that an underground storage tank was removed from the above referenced address on or
about November 10, 1997.Although the capacity of the tank documented with the BPHD(one-thousand
gallons)differs from that noted on the permit for storage tank removal(five-hundred gallons)information
exists to support that there was only one tank on the property.Records indicate that the house construction
and BPHD tank of record installation both occurred in 1978.Records supporting the existence of more than
one tank on the property do not exist.
The Public Health Division appreciates your attention to this matter and has updated its data base to
reflect this fuel tank status change. Should you have any further questions plea e co tact Cynthia Martin of
this office at 508-826-4645.
homas A. McKean, RS,CHO
Director of Public Health
3
_4
Make application to local Fire Department.
Fire Department retains original application and issues duplicate as Permit.
��e�iao�ii/2e�zCo��r�xe �vwlscce4— �acr�c�o� �'r�xe ✓%xeZ�e��i2
APPLICATION and PERMIT Fee: 10 . 00
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by:
•
Tank Owner Name (please print) Nyf G K X
Q9,�
rgnature t apllying or pemrrt
Address ,j o?.� �O)U/'T— I,A 'r' 02 1 Utz Co')-V►i` IJ/J-e)
Street City State Zip
Rem
oval
• •
• •
7 Company.Name-Ej o2d— Sr9c—.F co'e>p Co,or individual
Print + - Prnf
Address AC ISC x 3y 4 Ski G Y9 MAZE. /f3 Address
Print Print
Signature ' pplying for p it) Signature(if applying for permit)
JZI,(FCI Certified Other O IFCI Certified O LSP# Other
Tank Information'.
Tank Location S o� w j U!`i O/l I t/4 Go�1'T-
Steet Address city
Tank Capacity(gallons) _Substance Last Stored �27
Tank Dimensions(diameter x length) 3 7`C�
Remarks:
. . 0 Mt 1 �j
Firm ansporting waste �lJ f VZ.(�'
,:,.tr State Lic.#
Hazardous waste manifest# y��E.P.A. #
Approved tank disposal yard —1-0 U"-?— Tank yard# O
Type of inert gas ,U 0(� Tank yard address C0V—V) CVo . S'f— C''
Cotuit Fire District 01921 N/A
City or Town FDID# P rm' #
Date of issue . Date of expiration zx
Dig safe approval number: 1 Dig Safe Toll Free Tel. Number-800-322-4844
Signature/Title of Officer granting permit ,
After removal(s)send Form FP-290R signed by Local Fire pt. to UST Regulatory Compliance Unit, One Ashburton Place,
Room 1310, Boston, MA 02108-1618.
rr' 292 hnvtsn"l ntnri
RECEIPT OF DISPOSAL OF UNDERGROUND STEEL STORAGE TANK
NAME AND ADDRESS ;
OF Turner
APPROVED TANK YARD p,, n
APPROVED TANK YARD NO. C�8 S t.
Tank Yard Ledger 502 CMR 3.03 (4) Nu4ftr: -- -C� (�
I certify under penalty of law I have personall
y a-vdned the urdezgzournd steel storage tank
delivered to this "approved tank yard" by firm, corporation or partnership
and accepted same in conformance with Massachusetts Fire Prevention
Regulation 502 CMRwas issued
Previsions for eadro f Approving Steel Si r77e an�k dismantling�ards.
A valid pewit was issued by LOCAL }lead of Fire t FDIDi L to—
this tank to this yard.
Name offrt
icI=-
of approved tank yard owner or owners authorized representative:
SC-9 ( �e ( 0-q 7
SIGNAT[M TITLE DATE SIGNED
This signed receipt of disposal mist be returned to the local head of the fire department
FDIDt _ __ _ pursuant to 502 CMR 3:00. (EACH TAM MUSE HAVE A FirElPr OF DISPOSAL)
FORM F.P. 291 (rev. 11/95) (OVER) MAS.SACHUSUM STATE FIRE WJWAL'S OFFICE
I
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°FIMEr � Barnstable
Town of Barnstable
anMsrnsce,
sa
�f6o��a Regulatory ulator Services Department , Q
Public Health Division 2007
200 Main Street, Hyannis MA 02601
Office:508-862-4644 _. ... Thomas F.Geiler,Director
Fax:508-790-6304 Thomas A.McKean,CHO
To: Date: April 1, 2009.
Harold S. French&Ann M. Quinlin
525 Cotuit Bay Drive
Cotuit, MA 02635
RE: Underground Storage Tank at.
L� 0
p
525 Cotuit Bay Drive
Cotuit, MA 02635
Map Parcel: 055053
Tank NO: 1
Tag NO: 00560
Our records indicate.that your underground fuel (or chemical) storage tank is over 30
years old, and has not been removed as required by section 326-3: subsection 2.of the
Town of Barnstable Code regarding fuel and chemical storage systems.
You are directed to remove this tank within sixty(60) days from the date of this.notice..
After your tank is removed, please furnish this office evidence in the form of a permit
from your local Fire Department within ninety(90) days of the receipt of this notice.
You may request a hearing provided a written petition requesting same is received by the
Board of Health within ten(10) days after this order is served.
Per Order of the Board of Health
Thomas A. McKean, RS, CHO
Health Agent
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
OCT 2 8 2003
TOWN OF BARNSTABLE
HEALTH DEPT,
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 525 Cotuit Bay Drive ,
Cotuit, MA 02635 MAP
Owner's Name: Marcia Hackett PARCEL, ®� -
Owner's Address: LOT
Date of Inspection: October 7, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number:_ (508) 862-9400
CERTIFICATION STATEMENT
1 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:
✓ Passes
Conditionally Passes
Nee s Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: October 10, 2003
The system inspector shall subm' a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
i
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 525 Cotuit Bay Drive
Cotuit, MA
Owner: Marcia Hackett
Date of Inspection: October 7, 2003,
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or"filtration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by 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: r
2
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 525'Cotuit Bay Drive
Cotuit, MA
Owner: Marcia Hackett
Date of Inspection: October 7, 2003
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
r `
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 col iform
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.
' s
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 525 Cotuit Bay Drive
Cotuit, AM
Owner: Marcia Hackett
Date of Inspection: October 7, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
_ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z 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 SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/NO)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of.
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either`yes"or"no"to each of the following:.
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is.located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone'11 of a public water supply well
If you have answered"yes"to any question"in Section E the system is considered a significant threat, or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4 \
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Page 5 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 525 Cotuit Bay Drive
Cotuit, AM
Owner: Marcia.Hackett
Date of Inspection: October 7, 2003
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:.
Yes No
✓ Pumping information was provided by the owner,occupant, or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6.of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 525 Cotuit Bay Drive
Cotuit, MA
Owner: Marcia Hackett
Date of Inspection: October 7, 2003
FLOW .CONDITIONS
RESIDENTIAL
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
Number of current residents: 1
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): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERC IALA NDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): apd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Approx. 7 years ago-per owner
Was system pumped as part of the inspection(yes or no): No
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy €
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Apr. 11178-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of I 1
_ 3p
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address: 525 Cotuit Bay Drive
Cotuit, AM
Owner: Marcia Hackett
Date of Inspection: October 7 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron 40 PVC ' other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,'evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: To,grade
Material of construction: ✓ 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: 1500 gal.
Sludge depth: 2"
Distance from top of sludge'to bottom of outlet tee or baffle: 30"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or,baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,'inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
No inlet tee was present. An outlet tee was present. The liquid level was even with the outlet invert. There did not appear to be
any signs of leakage. Recommend pumping every three years for maintenance.'
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(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7'
Page 8 of i l
OFFICIAL INSPECTION FORM - NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 525 Cotuit Bay Drive
Cotuit, AM
Owner: Marcia Hackett i
Date of Inspection: October 7, 2003
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
t
I
8
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Page 9 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 525 Cotuit Bay Drive
Coto, AM
Owner: Marcia Hackett
Date of Inspection: October 7, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'- 1000 gal. w/Y stone (per design plans)
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.):
The pit had 4'of water on the bottom. The scum line was at the same level. There did not appear to be any signs offail ure. The
bottom to grade was 9. The cover was 20"below grade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet,mvert:
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: 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.):
9
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Page 10 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
`SYSTEM INFORMATION (continued)
Property Address: 525 Cotuit Bay Drive
Cotuit, MA
Owner: Marcia Hackett
Date of Inspection: October 7, 2003
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.
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10
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Page I 1 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 525 Cotuit Bay Drive
Cotuit, MA
Owner: Marcia Hackett
Date of Inspection: October 7,.2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
25'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. 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.
Il
........_...... 7. r FSS. ��.............._
THE COMMONWEALTH OF' MASSACHUSETTS
BOAR® OF HEA TH
..------..r ........OF........ .....................
Appliration for Diipnfial Narks Tonstrnr#inn ramit
Application is hereby made for a Permit to Construe or Repair ( ) an Individual Sewage Disposal
Syst a s /
Locatio ddre or Lot No.
......... .. ...... ~.:. ._. ..... ..._. ....................... ....._ - ....
her/ � �� ...............
Address s
a ...........s.' .............. _e.................. .....`-•-----------------e - ..............................
- �J'!"✓ Address
d _ Type of Building Size Lot.�.�n-17_Q_o___--Sq. feet
V Dwelling—No. of Bedrooms........ ................. .. .....Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons...................-------- Showers ( ) — Cafeteria ( )
Otherfixtures :-- -=----------•----------------.--••--------•-••---••-•-••--•......••-••-••--•••-•----•-•••--•-•--••-••--••-••••-•-........-----
W Design Flow.........570............................gallons per person per day. Total daily flow......... 4.o.._.........._.........gallons.
Ri Septic Tank—Liquid capacityl.Q:O_Ogallons Length................ Width................ Diameter------:-------.- Depth................
Disposal Trench—No. ............... idth..... ......... Total ength..-. ..___.._ •_. Total leaching area....................sq. ft.
Seepage Pit No.-. -0-.0-b-.- th ................. To al leaching area..................sq. ft.
z Other Distribution box ( ) Dosin to ( ) Gnh ' 9�/d�/7 7
~' Percolation Test Results Performed by- ..... .............
Test Pit No. L ........minutes per inch Depth of Test Pit.................... Depth to ground water-----...................
44 Test Pit No. 2.............:..minutes per inch Depth of Test Pit.................... Depth to ground water.---....................
P _ ---•--••_--•-- --.-- -. ..--- --- - -•--••--•-7-----
0 Descri Description of S r }
p oil. - .' l k[a >�s�tom(!` - �L- 'z r'r ..�1- r
x
•...
------------------------
W
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 iITLU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until.a Certificate of Compliance has been issued by e board of health.
S- ned ---•� --- ..... . ------•------------------ ----- .1.Z.._...0
//�J i rDate
Application Approved BY 1.�_.... __ .4l10_____ ________•__-----•---- -•----•-- � �.`..Z.&.....
_ Date
Application Disapproved for the following reaso ............................................ .... . ..........................................................
--.......-•............................•--•-•-•-•-....--•---..........er ---....... .... .
Date
PermitNo........................................................I ssued..../-L--•.... ? =--•---•-•-
Date
17
No-------- ff ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H EA TH
.........OF......
...........................
Appliratiou for Disposal Ifarks Tonstrudion rnmit
11 !%,
Application is hereby made for a Permit to Construe _1 or Repair an Individual Sewage Disposal
System a
Op.
............. ............ .......... . ......... .................................................................................................
Locatio ddre or Lot,,No.
Z
.......... .................................. ...........................................................
.... ........................ .. .............. .
r
....... ----------------------- .......................................
er Address
.... ................
Type of Building Size Lot-.........................Sq. feet
U
Dwelling—No. of Bedr oms......... ...................... Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................. Showers Cafeteria
,P4 Other fixtures ...............................................................................................................................
Design Flow----....... .............................gallons per person per day. Total daily flow..
W ..............................g�allons.
$X Septic Tank—Liquid*capacitA.�.Lt�gallons Length.............�.. Width................ Diameter________________ Depth....._.......__.
Z
Disposal Trench No. .................... Width.._. ........... Total .t Length............ ... Total leaching area....................sq. f t.
' . . Diameter._____
� � - N 4
Seepage Pit No. Lti_.♦"Li'l -el
. . 115iarijeter........ 'Depth be'l5wifil5t Total leqching area..................sq. ft.
Z Other Distribution box'(-' Dosin to 4,0% ..........17/ 7
17
Percolation Test Resu)ts Performed by._ Vj �............. 5................ Date.. ................................
Test Pit No. L-49.._.._._minutes per inch Depth of Test Pit.................... Depth to ground water..._.................._.
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit..............._._.. Depth to ground water.__.................___.
............ ..... ------------------------------
,2.... ... -------S."4 Y ..................................
0 Description of Soil-----....._ ---- ---*---- ----------------------------------
x 1-1
U .........................................................................................................................................................................................I...............
......................................... ..................................................
---------------------------------------------- --------------------------------------*---------------
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 T I T 1Z- 5.of the.State Sanitary Code— The undersigned further agrees not to place the system in
operation until a.Certificate of Compliance has been issued by#e board of health.
AV
%
ned....4. ......... ......
-----------------".... ... --------- ............ .......
Date
Application Approved By....1,.e.......... ....... ...... ...... .....7.41......
Date
_ 1�'—------------------------
-Application Disapproved for the following reasons:................................................................................................................
...........................................................................................................................................................................................
Date
PermitNo......................................................... IssuedL................................
........................
Date
THE,.COMMONWEALTH OF MASSACHUSETTS
BOARDF HEAL, T
........................... ..............OF... ............................................................................
rtifiratr o oaiq liaurr
THIS IS TO CERTIFY', hatfthe Individua), Sew �t ons rt�)
T, Disposal4Sys i pd"( or Rep-aired
..........
... ....... .......I.. ........... ........ --- ------------- .............. ......... . .......
by...... . ......Installer ♦ Z _ -----------
e, 7
... ...........t.�t,21 ..........................I................. ................ ............ .......................
has been installed in accordance with theprovisions of T 5 of The State Sanitary..Code as described -in the
,7" .
application for Disposal Works Construction Permit No.ffl:�.77..................... dated 7............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DAT&................................... ........................................ Ins ector........................................
----------------------------------------
THE COMMONWEALTH OF• MASSACHUSETTS
BIDARD OF HEALTHI
47
.......... ............... ...............OF../ ...... 7.......
No..........7-7 ....................................... ..............
................
Disposal Works 041nstrurtion r tt •
Permissi(�i s
hprebygranted.. . - ------------ .............S................................. ...... ... ...... ...... .... .........
.. ....to Constiuctor Repair t. ..an Individual Sewage Disposal System Y
at No.....;4t...i.�t......... I-11i".
... ......................................... ..................................................................................
-------------
�7 Street
as sho)Wn on the application for Disposal Works Construction Pe it a Dated-__3 ...............
j-rpe,...................................
Board of H'5*6h
DATE....1.��................ .........................................
FORM 1255 HOB13S & WARREN. INC.. PUBLISHERS.
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TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
OWNER AND INSTALLER INFORMATION
ADDRESS: S ,2 J— Co /t..• J55 W w �s C' MAP NO. 0 5 S PARCEL NO.
OWNER NAME: ' 1 V • r Wt� T i VILLAGE: ,: ! 4," 7—
AA/.t r�,►� M. JJ
INSTALLATION' DATE:a{.i.;a,�r. 41//fAl<y BY: a5,/ +- _ -, t. r d�"�-t'•- `. .+, f` S.�i ,'
ADDRESS: �f'° CERT. NO.
ftw,
3 4-
I NFORMAT I ON
•LOCATION OF TANK:
CAPACITY TYPE- 1 41-,� AGE . 10 zi. FUEL/CHEMICAL
TESTING CERTIFICATION E ] PASS E ] FAIL DATE
LEAK DETECTION E ] CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION E ] YES E)] NO DATE TO BE REMOVED —
FIRE DEPT. PERMIT ISSUED E 7 YES E ] NO DATE
-CONSERVATION E ] CHECK IF N/A DATE `
BOARD OF HEALTH TAG NO. b�]E ]E ],E : ]E ] DATE
PLEASE PROVIDE A SKETCH: SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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/// S M EA®
KEEPING YOU ORGANIZEDNo.10
334
2453L IMEINUSA
GET ORGANIZED AT SMEAD.COM
-
' LOCA;TION^ SEWAGE PERMIT NO.
VI Lit AGE "{
( F�a
TA LLE`R N ME & ADDRESS
/B U LDE`R FOR OWNER
DATE PERMIT ISSUE-D
DAT E C.OMPIIANCE ISSUED . 41 '
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