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HomeMy WebLinkAbout0035 FULLERS MARSH ROAD - Health 35 FULLE4WARSH dD. COTUIT 1 A = 006 041 i .I Commonwealth of Massachusetts ,•, h assac usetts ,p Title 5 Official Inspection Form` Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments- M 35 Fuller Marsh Road • Property Address James&Kristen Forbush Owner Owner's Na e a ' `. 36; information is Cotuit 7 F required for every Ma 02635 11-19=18 I5,? page. City/Town State Zip Code .Date of Inspection rep Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:WhenWhen filling out f A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector ' cursor-do not B&B Excavation use the return key. Company Name , 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 r� _ - _ S113747 Telephone Number License Number r B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority- 4. ❑ Fails •, Brett Hickey .p�"zbe�oo ���,...� ..�s 11-19-18 1 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. , Please note: 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. ' y, l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth ofMassachusetts Title 5 Official Inspection Form 1.. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: . ..,e ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection.The dwelling has a garbage grinder and the system is not designed for it. It is recommended that the grinder be removed to prolong the life of the SAS. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ,/p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I f' 35 Fuller Marsh Road Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain belowj:' ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r c \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road v Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) , ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Q Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.)' Yes No ❑ O Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Q Liquid depth in cesspool is less than 6" below invert or available volume is less 'than '/day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- El10,000 gpd. ❑ El 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. .5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ a Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ E] Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ El 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: Q ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'V 35 Fuller Marsh Road Property Address ` James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 4 Number of bedrooms(design): Number of bedrooms(actual): 440/gpd DESIGN flow based on 310 CMR 15.203(for example: 110 gpd,x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? Q Yes ❑ No Does residence have a water treatment unit? . ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 91 No information in this report.) Laundry system inspected? ❑ Yes E] No Seasonaluse? ❑ Yes [E No See below Water meter readings, if available (last 2 years usage(gpd)): Detail: ***2016-107,000gallons 2017-87,000gallons*** Sump pump? ❑ Yes ❑■ No current Last date of occupancy: . Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 r ' c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 4 years ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road v Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy T ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ ' Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of constr6ction: ❑cast iron ❑■ 40 PVC ❑other(explain)- Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): .t l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 ' e c Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road u Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 8„ Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gallon 611 Sludge depth: 3019 Distance from top of sludge to bottom of outlet tee or baffle NS Scum thickness On Distance from top of scum to top of outlet tee or baffle 0if Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road Property Address James&Kristen Forbush r , Owner Owner's Name information is required for every Cotuit t _ Ma 02635 11-19-18 -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): '. NA Depth below grade: feet Material of construction: ❑ concrete ❑,metal ❑fiberglass '❑ polyethylene ❑ other(explain): L , Dimensions: Scum thickness a 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I 8. Tight or Holding tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: - Material of construction: El concrete ❑ metal El fiberglass '❑ polyethylene ❑ other(explain): k . Dimensions: Capacity: gallons - - Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 _ t Commonwealth of Massachusetts �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 35 Fuller Marsh Road Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0'r Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts 1- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road Property Address James&Kristen Forbush Owner Owner's Name - information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes No' Alarms in working order: • ❑ Yes 0 No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation,not required): If SAS not located, explain why: ' Type: ❑ leaching pits number: (3)500 gallon chambers n leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields 'number, dimensions: r ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 e c Commonwealth of Massachusetts +m Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 35 Fuller Marsh Road Property Address James&Kristen Forbush Owner Owner's Name information is _ required for every Cotuit Ma 02635 11-19 18 page. -City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of pond ing, damp soil, condition of vegetation, etc.): The leaching was in working order and was dry with no high staining at time of inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes. ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts �1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road v— Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): - Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells Within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Asbuilt Groundwater profile 3'8" Rear A Leaching Chambers A1-12' 131.11' A2.20' 92.11' A3.22'6"133-6' 10 A4-40'6"B4.24' >51 0 t5insp.doc-rev.7126r2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form (�I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 35 Fuller Marsh Road v Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ❑N Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 12'feet Please indicate all methods used to determine the high ground water elevation: F-71 Obtained from system design plans on record If checked, date of design plan reviewed: .Perk log dated 9-23-98Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A perk log on file with the Board of Health was used. Before filing this Inspection Report;please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fuller Marsh Road v Property Address James&Kristen Forbush Owner Owner's Name information is Cotuit Ma 02635 11-19-18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 0■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked �■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed A D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS ' cL a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 TITLE.S OFFICIAL INSPECTION FORM-NOT FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 35 Fullers.Marsh Road Cotuit, MA 02635 Owner's Name: - Russell Cazeault Owner's Address: t ,. Date of Inspection:' October 2; 2007 h Name of Inspector: (Please Print).James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 t Osterville.MA 02655-0049 :" ' _�il C/1 Telephone Number: (508)862-9400 CERTIFICATION.STATEMENT r M I certify that I have personally inspected the sewage disposal system at this address.and;that the inform tion 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 tionally Passes. � Further Evaluation by the Local Approving Authority FP Inspector's Signature: Date: October 14 2007 The system inspector shall sub 't a copy of this inspection report.to the Approving Authority(Board of Health or. DEP)within 301days 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 Coniments 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., , Title 5 Inspection Form 6/15/2000 page.l Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS SESSMENTS SESSMEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:- .35 Fullers Marsh Road Cotuit. MA Owner's Name.: Russell Cazeault Date of Inspection: October 2; 2007 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 3 10 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 detennined(Y,N,ND)in the for the following statements. If"not detennined please explain. The septic tank is metal and over 20 years old* orthe septic tank(whether metal.or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved.by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available.. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due"to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping'more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the.Board of Health): broken'pipe(s)are replaced obstruction i"s removed ND explain:. 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35 Fullers Marsh Road Cotuit, M.4 Owner's Name: Russell Cazeault Date of Inspection: October 2 2007 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 CM 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System.will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and.environment: " The system has a,septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within .50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory; for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that fatality and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 _ - r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)' Property Address: 35 Fullers Marsh Road Co.tuit. MA, Owner's Name: Russell Cazeault Date of Inspection: October 2 2007 D. System Failure Criteria applicable to all systems: You must indicate either"yes or"no1ao 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 cesspool or clogged SAS or ✓ Liquid depth in cesspool is less'than 6"below invert or available volume is less than%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 groundwater 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 I of a public well. ✓ Any portion of a cesspool or privy is within50 feet of a private.watef 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 detennine 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 asurface drinking water supply the system is located in a.nitrogen sensitive area(Interim Wellhead Protection.Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in.Section E thesystem 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. - t 4 Page 5 of 11 4 OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 35 Fullers Marsh Road' Cetuit,MA Owner's Name: Russell Cazeault Date of Inspection: October 2 2007 Check if the following have been done: You must indicate" es"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? y ✓ — 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 breakout?" ✓ Were all system components, excluding the SAS,located on site? ✓ — Were theseptic 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. ✓ Detennined in fie 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 35 Fullers Marsh Road Cotuit MA Owner's Name: Russell Cazedult Date of Inspection: October.2, 2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage_grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n1a [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))t Unavailable Sump Pump(yes or no): No Last date of occupancy: _ Currently.occupied COMMERCIAL/INDUSTRIAL Type of.establishment: Design flow(based on 310 CMR 15.203): �' gpd 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: Tank was humped after the ins ection for maintenance 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: Installed on 813.0101 -per as built card Were sewage odors detected when arriving at the site(yes or no): No' 6 Page 7 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: 35 Fullers Marsh Road ' Cotuit. MA Owner's Name: Russell Caieault Date of Inspection: October 2. 2007 BUILDING SEWER(locate on site plan) Depth below grader 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: g,,- r Material of construction: ✓ concrete._metal fiberglass _polyethylene. _other(explain) If tank is metal list age: Is age confiniied by a Certificate of.Compliance(yes or no);certificate) (attach a copy of Dimensions: 1500.Qa1. ' Sludge depth: 211 Distance from top of sludge to bottom.of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6 *' Distance from bottom of scum to bottom of outlet tee-or baffle: 101, 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.); Tees were present. The liquid level was even with the outlet invert 'There did not appear to be any signs of leakage The tank was pumped after the inspection for maintenance GREASE TRAP: None (locate on site plan) ) , Depth below grade`. Material-of construction: concrete _metal _fiberglass'_polyethylene _other (explain): Dimensions: Scum thickness: r Distance from top of scum,to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recoitunendations, inlet and outlet tee or baffle condition, structural integrity, liquid,levels as related to outlet invert,evidence:of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM_INFORMATION(continued) Property Address: 35 Fullers Marsh Road Cotuit, MA Owner's Name: Russell Cazeault - Date of Inspection: October 2, 2007 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: gallonsfday Alarm present(yes or no): - Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alann and float switches, etc.): . DISTRIBUTION BOX: ✓' (if presentmust 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 and clean. 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) Cormments(note condition of pump chamber,condition of pumps and appurtenances;etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3_` Fullers Marsh Road Cotuit,MA Owner's Name: J rssell Cazeault Date of Inspection:. October-2 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why. Type - leaching pits,number: ✓ leaching chambers,number: 3-500 gal. chambers(34'x 13 5'-per as built card) leaching galleries,number: leaching trenches,number, length: leaching fields,number dimensions: overflow cesspool;number: Innovative/alternative s-stem Type/name of technology: Connnents(note condition of soil,signs of hydraulic failure, level ofponding, damp soil,condition of vegetation, etc.): The chambers were dry and clean. There did not al2pear to be any si ns o ailure. A video camera was.used for the inspection. CESSPOOLS:, None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet inve-t: 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 pyan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): r 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE WSPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 35 Fullers Marsh Road Cotuit, MA Owner's Name: Russell Cazeault Date of Inspection: October 2 .2007 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. 6 ask I _ a O 3 o a ao 3 PC � i _ you a y y f 10 Page 11 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSES SMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Fullers Marsh Road Cotuit: MA Owner's Name: Russell Cazeault Date of Inspection: October 2 2007 SITE EXAM ... Slope Surface water Check cellar Shallow wells Estimated depth'to.ground water 30+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on recordx-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of S'AS) ✓ Checked with local Board of Health-explain: topographic and water-contours mdps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain:' You must describe how you established the high ground water elevation; Using Barnstable topographic and water contours ritaps the maps were showing approxitnately 30'+% to ground water at this site. s w " This report'has been prepared only for the septic system and components described herein. This septic system has been 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 septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. Town of Barnstable � OF tHE tp� Regulatory Services s�rrsn+s Thomas F. Geiler,Director �$ ��� Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and.interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. ug 1214 09:42p p.1 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Fullers Marsh Road Property Address Wilfred Mathewson >. - Owner Owner's Name information dfo is MA °02635 8-12-14 required for every COtUIt +�`' ^ page. City/Town State Zip Code,,. Dale of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ` �pquuwpr OF As�ip�i on the computer, N M i use only the tab 1. Inspector: '' �� T g0�•� key to move your o��•. ^'•yG cursor-do not use the return James D.Sears =�, DAMES ;m key. Name of Inspector SIN :y Ca ewideEnter rises,LLC * rat Company Name p � t'�' 153 Commercial Street ' Arur+aa�nt��� - Company Address = Mashpee ,__ . MA 02649 City/Town State Zip Code 508-477-8877;. S 16_23 Telephone Number . License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection_ The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system:. ` ® Passes ` >❑ Conditionally Passes, __❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-12-14 nspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner ,and copies sentto the buyer, if applicable,and the approving authority. 1 ""This report onty 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. 11511. _ t5ns•3/13 y . Tide 5 offidal iupea on Form:Subsurface Sewage Disposal System•Page 1 of 17, IAug 1214 09;42p p.2 Commonwealth of Massachusetts Title 5 Official Inspection `Form ` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Fullers Marsh Road Property Address Wilfred Mathewson, a -' Owner Owner's Name information i e Cotuit MA_ 0263b^ 8-12-14 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E i�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: u ' The system is a 1500 Gal.tank D Box-and three dry well chambers.t' B) System Conditionally Passes: ❑ One or more system components as described in ttie°Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes". "no"or"not determined",(Y,'N,lND),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 exfillration or tank failure is imminent. System will pass in if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. El Y _ ,❑ N''' F 0 ND(Explain below) v r is 15ins-3H3* Title 5 Official Inspection Fornr.Subsurface Sewage Disposal System yst Paget of 17 Aug 12 14 09:43p p,3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fullers Marsh Road' Property Address Wilfred Mathewson Owner Owner's Name information is Coluit MA' 02635 8-12-14 required for every page- Citylrown state Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pump�s/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. , B) System Conditionally Passes(cont): - Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipes)are replaced• ❑,Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y• ❑ :N_ ❑ ND(Explain below):, ❑ distribution box is leveled or replaced ❑ Y ❑,N `❑ -ND(Explain below).. �1'4 � may. _ _ Y� - � ❑ 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 pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below):' ❑ obstruction'is removed ❑ Y ❑ N ❑ ND(Explain below): . ' C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board ofFHealth in order to determine if the system is failing to protect public health, safety or the environment. 1- Swstemv 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 dr a salt marsh :Sins-W13 ' Tale 5 Orrdet to F spection Farm:Subsnface Sewage Dlsposal System-Page 3 of 17 Aug 12 14 09:43p p.4 Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form _Not for Voluntary Assessments 35 Fullers Marsh Road - Property Address Wilfred Mathewson Owner Owner's Name information is required for every Cotuit i' MA 02635 8-12-14 _ page. City/Town Stale Zip Code Dale of Inspedlon B. Certification (cunt.) 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 100 feet of a surface water supply or tributary to a suifiace water supply_ ❑ The system has a septic tank and SAS and:the SAS is within a Zone 1 of a public water ❑ The system has a septic tank and SAS and the SASJs 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: n i;ii$ systern passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must 3. Other: D) System Failure Criteria Applicable to All Systems:You must indicate"Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or ❑ ® clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® * Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool , ❑ ® Liquid depth in Is less t�ian 6"below invert or available volume is less than day flow t�`�/�/N6 t5irrs 3113 Title 5 Otlicial Inspedon Form:Suhsur(aoe Sewage Disposal System•Page 4 of i7 Aug 12 14 09:43p r p.5 • Commonwealth of Massachusetts - z. - Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary_Assessments 35 Fullers Marsh Road Property Address Wilfred Mathewson Owner Owner's Name information is Cotuit MA 02635 8-12-14 r required for every _ page. Cityfrown State. Zip Code. Date of Inspection B. Certification (cont.) `:Y Yes No � - _. ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: s ❑ Z 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:pmry is within a Zone 1 of a public well. ❑ ® _, Any portion of a cesspool or privy is within 50 feet of a private'water supply well. ❑ ® Any portion of a cesspool or privy'is less"than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This *system passes if the well water analysis,performed at a DEP certified laboratory,for fecal colifonn bacteria.indicates absent and the presence yr arriawaiia iiiitiiogen and nitrate nitrogen, 7o i,.=_eat•.. ... _,^^t! a ,r�_.� provided that no other failure criteria are triggered. A copy 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 of 2000gpd- 10,000gpd. The system fails.I have determined that one or more of the above failure ❑ criteria exist as described in 310 CMR 16.303, therefore the system fails. The system'owner should contact the Board of Health to determine what will be necessary to correct the failure.' E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No Y ❑ ❑ 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'siy,^rificart thr Cu , ' 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 - • •, q;;,;�,,:.,;.,rh 3�n r ...1 1 z�� me s—tem owner should contact the appropriate regional office of the Department t5ins•3113 r Title 5 Office!Inspection Form:Subsurface Sewage Dispcsaf System-Page 5 or 17 Aug 12 14 09:44p p.6 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments, 35 Fullers Marsh Road Property Address Wilfred Mathewson F ' Owner Owner's Name information is : required for every Cotuit MA 02635 `8-12-14 page_ Cityrrown State Zip Code•,• .:. Date of Inspection C. Checklist Check if the following have,been done. You must indicate"yes"'or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by-tfie 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 pact of this inspection? ❑ s '' Were as built plans of the system obtained and examined?(If they were not available note as N/A). , 0, ❑ Was the facility or dwelling inspected for signs of'sewage back up? ® ❑ .Was the site inspected for signs of breakout? ® ❑ Were all system components, excluding the SAS,+°located on site? ® - ❑ - Were the septic tank manholes uncovered, ope'ned,'and the interior of the tank inspected for the condition of the bafftes,or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® ;Was the facility owner(and occupants if different from owner)provided with ,information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑, Existing information. For example, a plan at the Board of Health. ' = ❑ -0 Determined in the field(if any of the failure criteria related to Part C is at issue ..;approximation of distance is unacceptable)1310 CMR 15.302(5)] • t +`, - ^ D. System Information, P ; Residential Flow Conditions: : Number of bedrooms (design): 4 Number:of bedrooms(actual):, 4 DESIGN flow based on 310 CMR 15.203 (for example:,110'gpd•x#of bedrooms):' 440 t5ins af13 Title 5 Official Inspection ForT:6ubsuAaoe Sewage Dbpoeaf System•Page 6 of 17 .r - • _ u Aug 12 14 09:44p p.7 Commonwealth of Massachusetts u Title 5 Official Inspection Farm Subsurface Sewage Disposal.System Form-.Not for Voluntary Assessments 35 Fullers Marsh Road ` Property Address Wilfred Mathewson ` Owner Owner's Name information is Cotuit MA 62635 8=12-1.4 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information, '- Description: - 1500 Gal. tarik D Box and three 500 Gala dry well chambers. Number of current residents: 2 Does residence have a garbage grinder? ' ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report) Laundry system inspected? ❑ Yes ® No Seasonaluse? r ® Yes ❑ No Water meter readings, if available last 2 ears usage L d 2012-113,000GaI 1 9 Y 9 (9P )) 2013-124,000Gal's Detail: r Sump pump? ❑ Yes ® No Last date of occupancy:y NA Date Commercialilndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per day(gpd) Basis of design flow(seats/personsisq.ft., etc.): Grease trap resent? ..- P P, _ _ ❑ .Yes ❑ No Industrial waste holding tank present? t_ - 0 Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,'if available: t5lns•3113 _ rdle 5 Official Inspection Form:Suburface Sewage Disposal System-Page 7 of 17 P - Aug 12 14 09:44p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Fullers Marsh Road Property Address Wilfred Mathewson F r Owner Owner's Name - information is required for every Cotu[t MA 02635 8-12-14 page_ City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: : Date Other(describe below)_ f 3 GeneralInformation., . Pumping Records: Source of information: ` - ` NA T .; Was system pumped as part of the inspection?, ❑ Yes ® No If yes, volume pumped:, gallons ` . . How was quantity primped determined? Reason for pumping: L Type of Systein: ® Septic tank, distribution box, soil absorption system 3 a ❑, « Single cesspool _. ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes,'attach previous"inspection records, if any) ❑ Innovative/Alternative tech nology:'Attach-a copy of,the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract 'fight tank.'Attach a copy of the DEP approval. ❑ Other(describe): wins•3l13 T TWO 5 Ofl clal hspecUon Form:Subsurface Sewage Disposal System Page 8 of 17 1 Aug 12 14 09:45p _ p.9 Commonwealth of Massachusetts _ Title 5 Official Inspection Fou-m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments WO 35 Fullers Marsh Road Property Address - - Wilfred Mathewson Owner Owner's Name information is COtUIt required for every MA. 02635 : B-12-14" page. Citylrown State Zip Code Date of Inspection D. system Information Cont. Approximate age of all components,date installed(if known) and source of information: 1998 Permit # 98-621 Were sewage odors detected when arriving at the site? Yes ® No Building Sewer(locate on site plan): Depth below grade:' 4. w Meet Material 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_): Pipeing is 4" PVC SCH 40. - T Septic Tank(locate on site plan): , Depth below grade:' feet. Material of construction: ® concrete` ❑ metal .�.- ❑ fiberglass ❑'polyethylene _ ❑ other(explain) If tank is metal,.list age: <. years Is age confirmed by a Certificate of Compliance?:(attach a copy of certificate) D Yes [l No. Dimensions: 1500 Gal. Precast, H-10 F Sludge depth: 15ins f 3113 y.Title 5 OfGdar InsoecGan Form Subsurface Sewage Disposal System•Pe ge 9 of 17 • - j r - t Aug 1214 09:45p p.10 Commonwealth of Massachusetts. " Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Fullers Marsh Road- Property Address Wilfred Mathewson t Owner Owner's Name ' information is Cotuit MA 02635 8-12-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) - 281' Distance from top of sludge to bottom of outlet tee or baffle Scum thickness. z . Distance from top of scum to top of outlet tee or, baffle Distance from bottom of scum to bottom of outlet tee or baffle 17 ' How were dimensions determined? Asbuiit-Tape , Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to,outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 8"below grade. In and outlet tees. No sign of leakage or over loading. Grease Trap(locate on site plan):. Depth below grade:, feet Material of construction: Y ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: ' Scum thickness Distance from top of scum to top of outlet tee&baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping ry. pate 151ns•3113 Tile 5 Official Inspection Form:Subsurface sewage Disposal System•page 10 of 17 Aug 12 14 09:45p y r p.11 Commonwealth-of Massachusetts' Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 35 Fullers Marsh Road Property Address Wilfred Mathewson Owner Owner's Name information required for every Cotuit MA 02636 8-12-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction:. ❑ concrete [] metal' ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes '❑ No Alarm level: Alarm in working order, ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.):'. ` Attach copy of current`pumping contract(r"equired). Is copy attached? ❑`Yes y. ❑' No t5ins•3/13 Title 5 Q(bc lal Inspection Form.`Subsurface Sewage Disposal System-page 11 of 17 r„ r 4 ; Aug 12 14 09:46p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments E . 35 Fullers Marsh Road Property Address f Wilfred Mathewson Owner Owner's Name Information is Cotuit MA 02635 * . 8-12-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan) Depth of liquid level above outlet invert Comments (note if box is level'and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"x14'below grade. Box is clean and solid W/one line out. No sign of overloading or solid carry over:Note: Sprinkler line over D Box. Pump Chamber(locate on site plan): Pumps in working order: x - ="� 'El .Yes ❑ No• Alarms in working order .'' El Yes 0 No*- Comments (note condition of pump chamber;condition of pumps and appurtenances,etc.): * If pumps or alarms are not in working order, system is a conditional pass. Y, w Soil Absorption System (SAS) (locate on site plan, excavation not required):'`, If SAS not located, explain why: tSins-Sn3 , - .'r ''Title 5 t7Biaal Inspection Forrt;:Subsurface Sewage Disposal System•Page 12 of 17 Aug 12 14 09:46p p.13 Commonwealth of Massachusetts ---- Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Fullers Marsh Road Property Address Wilfred Mathewson Owner Owner's Name information is Cotuit MA. 02635 8-12-14 required for every • page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) s Type: k ❑ leaching pits: • number: ® leaching chambers A . number.. `. 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc_): , Leaching is three 500 Gal. dry well chambers w/4'stone. Chambers are W below grade. Chambers are dry w/clean wall's. No sign of over loading or high stain line., x Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and-configuration Depth—top of liquid toinlet invert Depth of solids layer u Depth of scum layer 4 Dimensions of cesspool Y Materials of construction . 4 ` Indication of groundwater inflow : ❑,Yes ❑ No t5ina•3M3, Title 5 Offidal Inspection Form:Suburfacs Sewage Disposal System•Page 13 of 17 Aug 12 14 09:46p p.14 ., R Commonwealth of Massachusetts Title 5 Official. Inspection Form 1 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r� 35 Fullers Marsh Road Property Address Wilfred Mathewson Owner Owners Name information is required for every Cotuit -MA 02635 8-12-14 page, Cityffown State -'Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc-): Privy(locate on site plan): j Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 or 17 ' .. t , r n Aug 12 14 09:47p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 35 Fullers Marsh Road Property Address Wilfred Mathewson Owner Owner's Name information is Cotuit MA 02635 $-12-14 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells withfn 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch fn the area below ❑ drawing attached separately EAR r o g • t ri d a h 4— ' 1 4 �_ t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17.- Aug 121409:47p p,16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . w 35 Fullers Marsh Road Property Address Wilfred Mathewson Owner Owner's Name information is Cotuit MA 02635 8-12-14 required for every - page. CitylTown State m Zip Code Date of Inspection D. System Information (cont.) w Site Exam: ❑ Check Slope , ❑ Surface water ❑ Check cellar w . ❑ Shallow wells Estimated depth to high groundwater '30+' 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(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Past Report - ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation-- G.W. 30+'per past report 10-14-07- ..i - Before filing this Inspection;Report, please see Report Completeness Checklist on next page. t5ins•3113 - - - Title 5 Otrclei inspection Form:Subsurface Sewep Disposal System-Page 16 of 17 .p ;.T _- - Aug 12 14.09:47p p.17 v t Commonwealth of Massachusetts Title 5 Official Inspection Form - , Subsurface Sewage Disposal System Form-Not for Voluntary,Assessments 35 Fullers Marsh Roads Property Address t Wilfred Mathewson Owner Owners Name w information is Cotuit MA 02635 { 8-12-14 required for every � , page. Cityrrown State -Zip Code ; Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 8, C, D, or E.checked r ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information- Estimated depth to high groundwater - ® Sketch of Sewage Disposal System either drawn on.page 15 or attached in separate file 2. 15ins•3/13 Tide 5 Official Inspection Form:Subsu4ace Sewage Disposal System•-Pege 17 of 17 ...a . _ LL. TOWN O BARNSTABLE 4 L3CATION ` U�IL�S M��S SEWAGE# . �%hLAGE e0' ASSESSOR'S MAP&PARCEL 06(0' 0y1 INSTALLERS NAME &PHONE NO. SEPTIC TANK CAPACITY �W I LEACHING FACILITY:(type) 3 ' sw9,�I C44*LJ1 (size) 3y x 3•S NO.OF BEDROOMS ^^y OWNER PERMIT DATE: 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 facility) Feet FURNISHED BY S rod (0/a I o- o a ;to y0� a . y y TOWN OF BARNSTABLE•E=C- w s LOCATION \`� ed'� hfl(Zs K RA, SEWAGE # VaI,LAGE Co�225 ASSESSOR'S MAP & LOTNjn- INSTALLER'S NAME&PHONE NO.GCXO.-ki4c— L4 a8 -aL16 3 SEPTIC TANK CAPACITY BOO LEACHING FACILITY: (type) DSOa&/ COI Adt'l MI n (size)-2y f 3"5 NO. OF BEDROOMS y ` BUILDER OR OWN r h' PERMITDATE: -a3 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 facility) Feet Furnished by ed 0 6 ri yo��" Q4t 00 No. L ' Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �! Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Miopo ar pgtem (Construction perratt Application for a Permit to Construct( )Repair( pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3� Fa l(ram 240 5 Owner's Name,Address and Tel.No. cJ✓ Assessor's Map/Parcel Co fute � G.�C�Yr� A Lj e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 2 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title 7-1-A—\\6 L I-1 A IRS� Zt - Size of Septic Tank Type of S.A.S. S Description of Soil l/i►W Na a of Repairs or Alterations(Answer when applicable) � l �v (9 '5 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue b o d .alth. Signed Date 51,e ;2 3 " S Application Approved by Date Application Disapproved for a following reaso Permit No. r Date Issued r . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Di-qpool *p!5tem Con6truction Permit Application for a Permit to Construct( ~)Repair( Upgrade( )Abandon( ) O Complete System ❑Individual Components LocationAdd rg�s or Lot No. 'j j�(r�'aid¢ `��f Owner's Name,Address and Tel.No. Assessor's Map/Parcel C,0 V 1 g Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ° Size of Septic Tank Type of S.A.S. ))��//f Description of Soil 6!'7a Natu a of Repairs or Alterations(Answer when applicable) t"A—) a v 0 5 119 A/t Date last inspected: .. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi Board of Health. ,.Signed '`� - Y � -,� � Date ! Application Approved by ;� Date s Application Disapproved for Ye following reaso 1 ? Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by ems. at j f Ao _ has e n constructed m accordance -with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer,.' Designer �� The issuance of this permit;hall not be construed as a guarantee that the§yste will function as designed. Date r, 1 f? Inspector �� l 4 -- — — ------------------------- No. Fee . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Migpozal 6potem Cougtruction Permit Permission is hereby granted to Construct )Repair( %Upgrade( Ab ndon( ) System located at 'rt '" f1 ! and as described in the above Application for Disposal System Construction Permit. The applicant recogn•.zes his/her duty to comply with Title 5 and the following local provisions or special conditions. i Provided: Constructio must be oo Ie within three years of the date of thi e it.-- Date: 7 / Approved by �J / 1 . NOTICE: This Form Is To Be TJsed For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, WI}lTQ2 JG w i S , hereby certify that the application for disposal works construction permit signed by me dated 5'Q,p� , concerning the property located at 3 �0 �y� eets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will=be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. .Please complete the following: A)Top of Ground Elevation (according to the Engineering Division G.I.S. map) l f B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cen Lr-' TOWN OF BARNSTABLE C LOCATION_,. .— ( l` ' n SEWAGE ##' 78 .VILLAGE Co L�1 I ASSESSOR'S MAP &.LOT INSTALLER'S NAME"&.PHONE NO.lrPh�- C „•.:SEPTIC TANI ,et ACITY l 500 G 1-I a8 �ay6 Ldn- LEACHING`FACILITY: (type) 5oo 6-al r . CZI C3 (size) .34/ 136 5� N.O. OF BEDROOMS BUILD ER OR O ,R ,.y r t� FERMITDATE: .� OMPLTANCE DATE Separation Distance Between.the: Maxurium Adjusted Groundwater Table to the BottotTi of Leachtng Faeihty Private Water Supply Well and Leaching Fact - Feet. g ty (IE any.we11s exis.G i on`s'ite or within 200 feet o ac f lehing facility) Edge of Wetland and LeachingFacility Feet ty (If any wetlands exist within 300 feet of leaching facility) I Feet' Furnished by A v 9 0 a ad jo